— 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、心跳過速及面臨災難的恐懼感，首要的護理處置為何？
A 45-year-old client with a history of generalized anxiety disorder presents with rapid breathing, tachycardia, and a sense of impending doom. Which intervention is the priority?
- AEncourage the client to discuss the cause of anxiety鼓勵病人討論焦慮的原因
- BInstruct the client to breathe into a paper bag指示病人向紙袋內呼吸
- CRemain with the client and maintain a calm environment✓ 正解陪伴病人並維持安靜的環境
- DAdminister an as-needed anxiolytic medication給予處方之按需鎮靜劑
— Explanation · 中文詳解 —
面對恐慌發作的病人，最關鍵的護理核心是確保安全感。護理師留置現場能降低個案的無助感，且平靜的態度能發揮模仿效應，有助於情緒的穩定。藥物雖有效，但需醫囑且非首要；過度詢問原因會增加壓力，呼吸紙袋法因可能導致嚴重缺氧已不再作為常規首選。
During an acute panic attack, the nurse's priority is to ensure the client's safety and reduce feelings of helplessness by remaining present and maintaining a calm environment. This supportive presence helps lower anxiety levels through modeling, whereas discussing triggers or using a paper bag is inappropriate during the peak of the episode.
✦ 台美臨床差異
美國護理師常受過專業危機介入訓練，台灣臨床則較常依賴醫師指示給予鎮靜劑。