一位 25 歲廣泛性焦慮症病史的個案至門診，主訴心悸、出汗及瀕死感。護理師確認為恐慌發作。此時護理師的優先處置為何？
A 25-year-old client with a history of generalized anxiety disorder presents to the clinic reporting heart palpitations, sweating, and a feeling of impending doom. The nurse identifies this as a panic attack. What is the nurse's priority intervention?
- AAdminister an ordered PRN anxiolytic medication給予處方之備用抗焦慮藥物
- BPerform a comprehensive physical assessment immediately立即進行全面的身體評估
- CInstruct the client to take deep, slow breaths✓ 正解指導病人進行深而緩慢的呼吸
- DAsk the client what triggered this episode詢問病人是什麼觸發了這次發作
面對恐慌發作的病人，首要目標是穩定病人的生理狀態並緩解極度焦慮。透過引導病人進行深慢呼吸，可以降低呼吸頻率，減輕過度換氣引起的身體症狀，從而穩定其情緒反應。其他選項雖然重要，但皆屬後續評估或給藥程序，非當下穩定病人最急迫的行動。
The priority intervention is to instruct the client to take deep, slow breaths to counteract hyperventilation and reduce physiological arousal associated with the panic attack. This immediate action helps stabilize the client’s respiratory status and anxiety level before addressing underlying triggers or administering medication.
美國護理師常依協定啟動減壓措施；台灣臨床常見先由醫師診視後再執行處置，但護理師引導呼吸屬於護理範疇，可直接執行。