一位 45 歲患有廣泛性焦慮症的個案出現呼吸急促與「瀕死感」。護理師應優先採取的介入措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents with rapid breathing and fear of 'impending doom.' Which nursing intervention is the highest priority?
- ASpeak to the client in a calm, clear, and concise manner✓ 正解以冷靜、清晰且簡潔的方式與病人說話
- BInstruct the client to breathe into a paper bag指示病人對著紙袋呼吸
- CLeave the client alone to reduce environmental stimuli讓病人獨處以減少環境刺激
- DAdminister an as-needed dose of benzodiazepine給予處方備用的苯二氮平類藥物劑量
面對焦慮發作的個案，建立安全感與控制感是首要目標。保持冷靜、清晰且簡潔的溝通能幫助個案降低焦慮強度。B 選項會導致缺氧風險，現代護理不再建議；D 選項雖有效，但非首要護理溝通介入；C 選項可能增加恐懼，應陪伴在旁以維護安全。
The highest priority intervention is to communicate in a calm, clear, and concise manner to help stabilize the client's emotional state and reduce anxiety. Paper bag rebreathing is contraindicated due to the risk of hypoxia, and leaving the client alone can exacerbate feelings of isolation and fear. Although medication may be necessary, establishing a therapeutic connection through communication is the immediate nursing responsibility.
美護理臨床強調以治療性溝通緩解發作；台灣臨床護理師常需兼顧行政工作，常直接選擇給予止焦慮藥物。