— 心理社會完整性 · EASY · MCQ —
一位 35 歲患有廣泛性焦慮症的個案，出現呼吸急促並自述有瀕死感。護理師首要採取的措施為何？
A 35-year-old client with a history of generalized anxiety disorder presents with rapid breathing and reports a feeling of impending doom. Which intervention is most appropriate for the nurse to perform first?
- AStay with the client and maintain a calm, quiet environment✓ 正解留在客戶身邊並維持安靜、平和的環境
- BAdminister an anxiolytic medication as ordered依醫囑給予抗焦慮藥物
- CTeach the client deep breathing exercises教導客戶深呼吸練習
- DEncourage the client to discuss the underlying causes of the anxiety鼓勵客戶討論焦慮的根本原因
— Explanation · 中文詳解 —
面對急性焦慮發作的病人，建立安全感與穩定情緒是首要目標。護理師留在身邊可提供支持並降低刺激，防止症狀惡化。藥物給予屬次要步驟，深呼吸教學應在病人情緒穩定後進行，深入探討原因則會增加壓力，不適合在急性期執行。
The priority intervention for acute anxiety is to stay with the client and maintain a calm, quiet environment to reduce sensory overload. This provides immediate safety and emotional support, whereas teaching or exploring causes should wait until the client is stabilized.
✦ 台美臨床差異
美國護理師在焦慮管理中角色較獨立，可直接應用多項護理措施，台灣則多遵循醫囑給予抗焦慮劑。