— 心理社會完整性 · EASY · MCQ —
一位 45 歲焦慮症患者出現呼吸急促、心搏過速及強烈瀕死感。護理師應優先採取何種措施？
A 45-year-old client with a history of generalized anxiety disorder presents with rapid breathing, tachycardia, and a feeling of impending doom. Which action should the nurse take first?
- AMaintain a calm demeanor and stay with the client✓ 正解保持鎮定的態度並陪伴病患
- BPerform a thorough neurological assessment進行詳細的神經系統評估
- CAdminister an as-needed dose of anxiolytic medication給予處方劑量的鎮靜藥物（as-needed dose）
- DInstruct the client to breathe into a paper bag指導病患向紙袋內呼吸
— Explanation · 中文詳解 —
面對急性焦慮發作，首要任務是提供安全且穩定的心理環境。護理師留在身邊不僅能降低患者的恐懼，還能持續監測病情變化。過度干預如給藥需依醫囑，紙袋呼吸已非目前標準做法，因為可能導致嚴重缺氧；而神經檢查在急性焦慮發作時非優先任務。
During an acute anxiety attack, the nurse’s priority is to provide a safe, calming presence to reduce the client's fear and ensure safety. While assessments and medications are important, they are secondary to immediate psychological stabilization, and paper bag breathing is contraindicated due to hypoxia risks.
✦ 台美臨床差異
台灣醫院中，護理師常需優先評估是否為生理疾病導致的焦慮（如心肌梗塞），美國則強調護病關係的治療性溝通。