一位 25 歲廣泛性焦慮症病患至門診，主訴持續擔憂與身體緊繃。護理師在初期評估時應優先採取何種措施？
A 25-year-old client with a history of generalized anxiety disorder presents to the clinic reporting persistent worry and physical tension. Which nursing intervention is prioritized during the initial assessment?
- AEstablish a therapeutic, non-judgmental relationship✓ 正解建立治療性、非批判性的關係
- BAdminister an ordered anxiolytic medication給予處方之抗焦慮藥物
- CRefer the client to a support group轉介病人至支持團體
- DInstruct the client on deep breathing exercises指導病人進行深呼吸練習
在心理衛生護理中，建立治療性護病關係（Therapeutic Relationship）是所有介入的核心前提。對於廣泛性焦慮症（GAD）病人，由於其處於高焦慮與身體緊繃狀態，若未先建立信任感（Trust），病人無法感到安全，後續的衛教、藥物衛教或諮商皆會受阻。優先級原則為安全與關係建立，而非直接進行技術性操作或給藥，因為焦慮的緩解需要病人的主動參與與配合。
Establishing a therapeutic, non-judgmental relationship is the priority intervention to build trust and ensure the client feels safe enough to engage in further assessment and treatment. Without this foundational rapport, other interventions such as medication administration or teaching deep breathing techniques are less likely to be effective.
台美臨床皆重視護病關係，但美國護理師在心理衛生護理中更強調自主權與動機式晤談（Motivational Interviewing），鼓勵病人主導治療方向，而非單向式指引。