— 心理社會完整性 · EASY · MCQ —
一位 28 歲廣泛性焦慮症病人出現心跳過快、顫抖及瀕死感。護理師應優先執行何種措施？
A 28-year-old client with generalized anxiety disorder presents with rapid heart rate, trembling, and a feeling of impending doom. Which intervention should the nurse perform first?
- AAdminister the prescribed PRN anxiolytic medication給予處方的 PRN 抗焦慮藥物
- BReduce environmental stimuli by moving to a quiet room✓ 正解移至安靜房間以減少環境刺激
- CAsk the client to explain the source of their anxiety詢問病人解釋其焦慮的來源
- DInstruct the client to practice deep breathing exercises指示病人練習深呼吸運動
— Explanation · 中文詳解 —
面對急性焦慮發作，環境控制是首要步驟。減少外在刺激能降低病人的感官負擔，有助於情緒平復。深呼吸（D）雖然有效，但病人若處於極度恐慌中，需要護理師引導且環境穩定才執行。詢問原因（C）會增加病人的認知負荷，非急性期首選。
The priority intervention is to reduce environmental stimuli by moving the client to a quiet room, as decreasing sensory input helps the client regain self-control during an acute anxiety episode. While deep breathing is a useful coping skill, it requires a calm environment to be effective, and analyzing the source of anxiety is counterproductive when the client is panicked.
✦ 台美臨床差異
美國護理環境多強調隱私與安寧；台灣急診或病房空間較擁擠，護理師需運用屏風或轉移病室來執行環境控制。