一名 25 歲、有廣泛性焦慮症病史的個案到診所就診，表示 20 分鐘前開始出現心悸、呼吸急促與瀕死感。護理師應先採取哪一項行動？
A 25-year-old client with a history of generalized anxiety disorder comes to the clinic and reports that palpitations, shortness of breath, and a feeling of impending doom began 20 minutes ago. Which action should the nurse take first?
- AObtain vital signs and oxygen saturation and assess for a cardiac or respiratory cause測量生命徵象與血氧飽和度，並評估是否有心臟或呼吸系統的原因正確答案
- BAdminister the client's prescribed as-needed dose of oral lorazepam right away立即給予個案醫囑中需要時（PRN）使用的口服 lorazepam
- CAsk the client to describe what happened just before the symptoms started today請個案描述今天症狀出現前發生了什麼事
- DTeach the client relaxation techniques to use if the symptoms occur again later教導個案日後症狀再發作時可以使用的放鬆技巧
- A測量生命徵象與血氧飽和度，並評估是否有心臟或呼吸系統的原因
正確答案是 A。心悸、呼吸困難、胸部不適與瀕死感是恐慌發作的典型表現，但同樣可能來自心肌梗塞、心律不整、肺栓塞、氣喘、低血糖或甲狀腺功能亢進。即使個案有焦慮症病史，護理過程仍必須從評估開始：先測量生命徵象與血氧飽和度，必要時依流程做心電圖與血糖，排除危及生命的生理原因；DSM-5-TR 對恐慌發作的判定也要求症狀不能由其他生理疾病或物質所引起。確認生理狀況穩定後，護理師才陪伴個案、以平靜簡短的語句說話、減少環境刺激並引導緩慢呼吸。B：需要時使用的抗焦慮藥須依醫囑給予，且在未排除生理病因前用藥可能掩蓋急症的表現。C：探索誘發事件會加重急性期的焦慮，應等情緒穩定後再進行。D：教導放鬆技巧屬於後續衛教，不是此刻的第一步。來源：American Psychiatric Association, DSM-5-TR（恐慌發作）；Halter, Varcarolis' Foundations of Psychiatric-Mental Health Nursing。
- A · 正確答案測量生命徵象與血氧飽和度，並評估是否有心臟或呼吸系統的原因
正確。心悸與呼吸困難可能來自心肌梗塞、心律不整或肺栓塞，護理過程須先評估生命徵象與血氧，排除危及生命的生理原因。
- B立即給予個案醫囑中需要時（PRN）使用的口服 lorazepam
錯誤。需要時使用的抗焦慮藥須依醫囑給予，且在未排除生理病因前用藥可能掩蓋急性心肺問題的表現。
- C請個案描述今天症狀出現前發生了什麼事
錯誤。急性發作時要求個案回想誘發事件會加重焦慮，探索誘因應等生理狀況穩定、情緒緩和後再進行。
- D教導個案日後症狀再發作時可以使用的放鬆技巧
錯誤。教導放鬆技巧是症狀緩解後的衛教內容，無法處理此刻尚未釐清的生理風險。
美國門診與急診對主訴心悸、呼吸困難的個案，常規先測量生命徵象並做心電圖分流，之後才考慮精神科診斷；台灣臨床遇到有焦慮病史者較容易直接歸因於焦慮並先給藥，護理師更需堅持先完成生理評估再處置。
English explanation
Option A is correct. Palpitations, shortness of breath, chest discomfort, and a sense of impending doom are classic features of a panic attack, but the same symptoms occur with myocardial infarction, dysrhythmias, pulmonary embolism, asthma, hypoglycemia, and hyperthyroidism. Even when the client has a documented anxiety disorder, the nursing process begins with assessment: the nurse obtains vital signs and oxygen saturation and, according to protocol, an electrocardiogram and blood glucose, so that a life-threatening physiologic cause is ruled out. The DSM-5-TR also requires that panic attack symptoms not be attributable to another medical condition or to a substance. Once the client is physiologically stable, the nurse stays with the client, speaks calmly in short sentences, reduces environmental stimuli, and guides slow breathing. Option B is incorrect because an as-needed anxiolytic requires a prescription, and giving it before a physiologic cause is excluded may mask an emergency. Option C is incorrect because exploring precipitating events raises anxiety during the acute phase and is done after the client has settled. Option D is incorrect because teaching relaxation techniques is follow-up education rather than the first action. Source: American Psychiatric Association, DSM-5-TR (panic attack); Halter, Varcarolis' Foundations of Psychiatric-Mental Health Nursing.
最近修訂：2026-10-06