— 心理社會完整性 · EASY · MCQ —
一位 45 歲患有廣泛性焦慮症的個案，主訴心悸與顫抖。護理師應優先採取的護理措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents with reports of palpitations and trembling. Which initial nursing intervention is most appropriate for the nurse to implement?
- AAsk the client to list all current stressors請個案列出所有目前的壓力源
- BInstruct the client to practice deep breathing exercises✓ 正解指導個案練習深呼吸運動
- CEncourage the client to ventilate feelings鼓勵個案抒發感受
- DAdminister an as-needed dose of benzodiazepine給予處方劑量的苯二氮平類藥物
— Explanation · 中文詳解 —
面對焦慮引發的生理反應（心悸、顫抖），首要目標是減輕生理喚起狀態。深呼吸能啟動副交感神經，幫助個案快速緩解焦慮症狀，是護理師最直接且有效的非藥物處置。A 與 C 屬於諮商層面，需在情緒穩定後進行；B 需醫囑。
Instructing the client to practice deep breathing exercises is the most appropriate initial intervention as it activates the parasympathetic nervous system to reduce autonomic arousal. This non-pharmacological approach directly addresses the physiological symptoms of palpitations and trembling associated with acute anxiety.
✦ 台美臨床差異
美台護理臨床對於急性焦慮處理皆強調非藥物處置先行，但美國更強調護理師獨立執行呼吸引導的權限。