— 心理社會完整性 · EASY · MCQ —
一名有廣泛性焦慮症病史的 45 歲個案，表現出心跳過速、顫抖及瀕死感。護理師首要介入措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents with rapid heart rate, tremors, and a sense of impending doom. Which intervention is most appropriate for the nurse to implement initially?
- ATeach the client deep breathing exercises教導病人深呼吸練習
- BEncourage the client to ventilate feelings鼓勵病人抒發感受
- CAdminister PRN anxiolytic medication給予 PRN 抗焦慮藥物
- DReduce environmental stimuli✓ 正解減少環境刺激
— Explanation · 中文詳解 —
面對急性焦慮症狀，首要步驟是降低環境刺激，因為過多刺激會加劇病人的過度警覺與焦慮反應。維持環境平靜有助於讓病人先降至可進行溝通的心理狀態。深呼吸練習雖有效，但需在環境安靜後執行；藥物與表達情感均為後續介入。
Reducing environmental stimuli is the priority intervention for acute anxiety, as excessive stimulation can worsen the client's sense of impending doom. Creating a calm environment helps lower arousal levels, allowing the client to eventually engage in coping strategies like deep breathing.
✦ 台美臨床差異
台美臨床皆強調降低感官刺激，但在美國社區護理中，會更強調鼓勵病人建立自己的『安全空間』設定。