— 心理社會完整性 · EASY · MCQ —
一位 45 歲焦慮症病人，出現呼吸急促、心跳過速及瀕死感。護理師應優先採取何種護理措施？
A 45-year-old client with a history of generalized anxiety disorder presents with rapid breathing, tachycardia, and a sense of impending doom. Which intervention is the highest priority for the nurse?
- AEncourage the client to discuss the source of their anxiety鼓勵個案討論焦慮的來源
- BMaintain a calm, quiet, and low-stimulus environment✓ 正解維持安靜、平靜且低刺激的環境
- CInstruct the client to breathe into a paper bag指示個案對著紙袋呼吸
- DAdminister an as-needed dose of lorazepam給予處方劑量的勞拉西泮（lorazepam）
— Explanation · 中文詳解 —
面對恐慌發作的病人，首要之務是降低環境刺激，幫助病人降低焦慮等級。過多的感官刺激會加劇病人的失控感。紙袋呼吸法因可能導致缺氧已不再建議。給予藥物雖有效，但非第一時間的非侵入性護理措施。討論焦慮源應在急性症狀緩解後進行。
The highest priority intervention for a client in acute panic is maintaining a calm, quiet, and low-stimulus environment to help reduce anxiety levels quickly. Excessive sensory stimulation can exacerbate feelings of loss of control. Paper bag breathing is no longer recommended due to hypoxia risks, and medication or discussion should follow initial environmental stabilization.
✦ 台美臨床差異
美台護理臨床對於恐慌病人的處置標準相似，均強調環境安全與同理心引導。