— 心理社會完整性 · EASY · MCQ —
一位 45 歲患有廣泛性焦慮症的病人表示感到心悸、發抖且有一種瀕死感。護理師應優先採取何種措施？
A 45-year-old client with a history of generalized anxiety disorder presents with reports of palpitations, tremors, and a sense of impending doom. Which intervention should the nurse prioritize?
- AAdminister an as-needed benzodiazepine給予處方備用的苯二氮平類藥物
- BInstruct the client to breathe slowly with the nurse✓ 正解指導病人與護理師一起緩慢呼吸
- CPerform a comprehensive physical assessment進行全面性身體評估
- DEncourage the client to talk about their stressors鼓勵病人談論其壓力來源
— Explanation · 中文詳解 —
面對急性焦慮發作，病人的交感神經系統過度興奮，常出現過度換氣（Hyperventilation）導致二氧化碳分壓過低，引發頭暈、手麻等症狀。護理師的首要介入應是減輕病人的生理喚起狀態。引導式深呼吸（Deep breathing）能直接活化副交感神經，協助減緩心跳並穩定呼吸，是護理師在第一時間能立即執行且最有效的非藥物處置。
During an acute anxiety attack, the sympathetic nervous system is overactive, often causing hyperventilation and physiological arousal. The nurse should prioritize guided slow breathing to activate the parasympathetic nervous system, which helps reduce heart rate and stabilize respiration immediately.