— 心理社會完整性 · EASY · MCQ —
一名 35 歲廣泛性焦慮症患者出現心悸、出汗及瀕死感。護理師在急性期應優先採取哪項介入措施？
A 35-year-old client with a history of generalized anxiety disorder presents with reports of palpitations, sweating, and feelings of impending doom. Which intervention is the nurse's priority during the acute phase?
- AInstruct the client to breathe slowly into a paper bag指導病人用紙袋慢速呼吸
- BMaintain a calm, quiet, and non-stimulating environment✓ 正解維持安靜、平和且無過度刺激的環境
- CAdminister an as-needed anxiolytic medication給予按需使用的抗焦慮藥物
- DTeach the client deep breathing techniques教導病人深呼吸技巧
— Explanation · 中文詳解 —
面對焦慮急性發作，首要目標是減少環境刺激以降低病人的過度喚起狀態。給予安全感和控制環境是護理照顧的基石。使用紙袋呼吸現已不建議，因可能導致缺氧；藥物需醫囑；教學技巧應在急性症狀緩解後進行，急性期無法學習。
During an acute anxiety attack, the priority is to reduce environmental stimuli to help lower the client's arousal level. The nurse should maintain a calm, quiet, and non-stimulating environment, as teaching or medication administration is less effective or feasible during the peak of panic.
✦ 台美臨床差異
台美均強調病室環境控制，美國較重視護理師在護理記錄中詳細描述去激化（de-escalation）過程。