護理師正在照顧一位患有廣泛性焦慮症 (GAD) 的病人。病人正在踱步、過度換氣，並說：「我覺得我心臟病發作了！」護理師應首先實施哪項干預措施？
A nurse is caring for a client with Generalized Anxiety Disorder (GAD). The client is pacing, hyperventilating, and states, 'I think I'm having a heart attack!' Which intervention should the nurse implement first?
- ATeach the client about the long-term effects of anxiety教導病人關於焦慮的長期影響
- BAsk the client to explain what triggered the anxiety請病人解釋引發焦慮的原因
- CAdminister a PRN dose of an antidepressant給予處方備用劑量的抗憂鬱藥
- DStay with the client and use short, simple sentences✓ 正解陪伴病人並使用簡短、簡單的句子
當病人處於嚴重焦慮或恐慌狀態時，其感知野會大幅縮小，無法吸收複雜資訊或進行深層思考。首要護理目標是建立安全感並降低生理焦慮。維持護理師的現身（Presence）能提供情感支持並確保病人安全。使用簡短、清晰的句子是有效的溝通方式，因為此時病人的認知功能受限。這體現了急性期護理的「支持性干預」原則，先穩定情緒與生理徵象，再進行後續的衛教或原因探討。
During an acute anxiety episode, the client's perceptual field narrows, making complex teaching or exploration of triggers ineffective. The priority nursing intervention is to stay with the client to provide safety and use short, simple sentences to facilitate communication, thereby reducing environmental stimuli and helping to stabilize the client's physiological state.
美國 NCLEX 非常看重「Presence」（現身/陪伴）作為治療性措施的價值。台灣臨床環境中，護理師因病人數多，有時會傾向先給予 PRN 藥物（如 Xanax）而縮短陪伴時間，但國考標準仍以非藥物支持為優先首選。