— 心理社會完整性 · EASY · MCQ —
一位 35 歲廣泛性焦慮症病史的個案，出現呼吸急促、心搏過速及強烈瀕死感。護理師首要行動為何？
A 35-year-old client with a history of generalized anxiety disorder presents with rapid breathing, tachycardia, and a sense of impending doom. Which action is the nurse's priority?
- AAdminister an as-needed dose of an anxiolytic給予處方之焦慮解劑按需劑量
- BPerform a comprehensive neurological assessment進行全面的神經系統評估
- CStay with the client and maintain a calm, quiet environment✓ 正解陪伴個案並維持安靜平和的環境
- DEncourage the client to discuss the source of anxiety鼓勵個案討論焦慮的來源
— Explanation · 中文詳解 —
當病人出現廣泛性焦慮症（GAD）急性發作，伴隨生理症狀如心搏過速、呼吸急促及瀕死感時，首要任務是提供安全感與減少環境刺激。護理師留在病人身邊能防止病人發生傷害，並透過安靜的環境協助病人穩定情緒。在病人極度焦慮狀態下，無法進行深度的心理諮詢或複雜的評估，穩定生理與心理狀態是優先順序（Priority）。
During an acute anxiety attack, the nurse's priority is to ensure safety and reduce environmental stimuli by staying with the client and maintaining a calm presence. This approach helps stabilize the client's physiological and psychological state. Complex assessments or cognitive discussions are ineffective while the client is in a heightened state of panic.