— 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恐慌發作，護理師觀察到過度換氣和震顫。護理師應優先執行哪項措施？
A 45-year-old client with a history of generalized anxiety disorder presents with a panic attack. The nurse observes hyperventilation and tremors. Which intervention should the nurse perform first?
- AAsk the client what triggered this panic attack詢問個案是什麼觸發了這次恐慌發作
- BInstruct the client to breathe into a paper bag指示個案對著紙袋呼吸
- CSpeak in a calm, firm, and concise manner✓ 正解以冷靜、堅定且簡潔的方式說話
- DAdminister an as-needed PRN dose of lorazepam給予處方劑量的lorazepam（按需使用）
— Explanation · 中文詳解 —
恐慌發作時，個案的認知功能下降，無法處理複雜問題。護理師應使用簡短、清晰且冷靜的指導語，協助個案恢復理智並降低環境刺激。A 不再建議使用，因可能導致缺氧；C 需醫囑且非首要步驟；D 個案當下情緒激動，分析原因會增加挫折感。
During a panic attack, the nurse should speak in a calm, firm, and concise manner to help de-escalate the client's anxiety and provide a sense of security. This clear communication helps restore cognitive function, whereas analyzing triggers or administering medication are secondary steps taken after the client has stabilized.
✦ 台美臨床差異
台美護理師皆強調恐慌發作時的冷靜溝通，但美國護理師依 protocol 給予抗焦慮藥物的彈性較大。