— 心理社會完整性 · EASY · MCQ —
一位 45 歲患有廣泛性焦慮症的個案出現呼吸急促、心跳過快及瀕死感。護理師應採取的優先行動為何？
A 45-year-old client with a history of generalized anxiety disorder presents with rapid breathing, tachycardia, and a sense of impending doom. What is the nurse's priority action?
- AAdminister the prescribed PRN anxiolytic medication給予處方 PRN 抗焦慮藥物
- BRemain with the client and maintain a calm, quiet environment✓ 正解陪伴個案並維持安靜平和的環境
- CInstruct the client to breathe slowly into a paper bag指導個案用紙袋緩慢呼吸
- DTeach the client about coping mechanisms for anxiety教導個案焦慮的因應機制
— Explanation · 中文詳解 —
面對恐慌發作的個案，護理師應留在個案身邊，提供安全感。環境控制（降低外界刺激）有助於降低個案的焦慮程度。C選項（紙袋呼吸）已被證實可能引發缺氧，不再建議使用；A選項（給藥）需確認醫囑；D選項（教導機制）應在個案情緒穩定後進行。
The priority action is to remain with the client and maintain a calm, quiet environment to promote safety and reduce physiological arousal. Paper bag breathing is no longer recommended due to the risk of hypoxia, and teaching or medication administration should occur only after the acute episode stabilizes.
✦ 台美臨床差異
台灣醫院常規下，恐慌發作時常會先由醫師評估是否給予鎮靜藥物；美國則更強調護理師運用認知策略穩定情緒。