— 心理社會完整性 · EASY · MCQ —
一位 45 歲患有廣泛性焦慮症的個案說：「我覺得我現在快要死掉了。」個案正在過度換氣並來回踱步。護理師的首要護理措施為何？
A 45-year-old client with a history of generalized anxiety disorder states, 'I feel like I am going to die right now.' The client is hyperventilating and pacing. What is the nurse's priority intervention?
- AStay with the client and use short, simple sentences✓ 正解留在病人身邊並使用簡短、簡單的句子溝通
- BAdminister the prescribed PRN anxiolytic medication給予處方備用 (PRN) 抗焦慮藥物
- CAsk the client to explain why they feel this way請病人解釋他們為何有這種感覺
- DEncourage the client to sit down and drink cold water鼓勵病人坐下並喝冷水
— Explanation · 中文詳解 —
面對急性焦慮發作，護理師應先提供安全感與穩定性。保持陪伴可降低病人的不安感，使用簡短明瞭的語言能避免增加認知負擔，有助於個案恢復控制感。藥物雖可緩解但非首要介入，探詢原因應在情緒穩定後進行，以免加劇個案壓力。
The priority intervention is to stay with the client and use short, simple sentences to establish a safe, calming environment. This presence helps reduce anxiety and cognitive overload during an acute panic attack. Administering medication or asking for explanations are secondary interventions that should occur only after the client is stabilized.
✦ 台美臨床差異
美台護理臨床對於恐慌發作的處置原則相似，重點均為陪伴與誘導呼吸控制。