— 心理社會完整性 · EASY · MCQ —
一名 45 歲患有廣泛性焦慮症的客戶，表現出呼吸急促、心悸和強烈的瀕死感。護理師應優先採取的措施是什麼？
A 45-year-old client with a history of generalized anxiety disorder presents with rapid breathing, heart palpitations, and a sense of impending doom. Which intervention is the highest priority for the nurse?
- AEncourage the client to talk about the source of anxiety鼓勵個案談論焦慮的來源
- BInstruct the client to breathe slowly with the nurse✓ 正解指導個案與護理師一起緩慢呼吸
- CAdminister an as-needed benzodiazepine給予按需使用的苯二氮平類藥物
- DLeave the client alone to reduce environmental stimuli讓個案獨處以減少環境刺激
— Explanation · 中文詳解 —
面對恐慌發作的病人，首要任務是降低生理上的過度換氣，以穩定生理功能。透過護理師引導慢呼吸，能有效降低交感神經興奮。B 需要醫囑，且非首要；C 在急性期無法達成，病人無法邏輯思考；D 違反安全護理原則，恐慌病人不可獨處。
During a panic attack, the priority is to stabilize physiological arousal by guiding the client through slow, deep breathing to counteract hyperventilation and calm the autonomic nervous system. Complex discussions or leaving the client alone are inappropriate as they may increase anxiety or safety risks, while medication requires orders and is secondary to immediate non-pharmacological stabilization.
✦ 台美臨床差異
美台護理臨床對於恐慌處置原則一致，皆強調陪伴與呼吸調控。