護理師照護一位嚴重焦慮的病人，應優先採取哪項干預措施？
A nurse is caring for a client with severe anxiety. Which intervention should the nurse implement first?
- AAdminister an as-needed (PRN) dose of lorazepam給予處方箋劑量的勞拉西泮
- BStay with the client and use a calm, low-pitched voice✓ 正解陪伴病人並使用平靜、低沉的聲音
- CAsk the client to explain what triggered the anxiety請病人解釋引發焦慮的原因
- DTeach the client deep breathing techniques教導病人深呼吸技巧
面對處於『嚴重焦慮』（Severe Anxiety）程度的病人，首要任務是確保其安全並降低環境壓力。嚴重焦慮會使病人的感知範圍明顯縮小，此時病人無法吸收新資訊或進行問題解決（如學習呼吸技巧或分析原因）。護理師的『陪伴』能提供立即的安全感，而『冷靜、低沈的語氣』能產生調節作用，幫助病人回穩。這是精神科護理的安全優先原則。在病人尚未平復前，探究原因或進行教學都是無效且可能加重焦慮的。
The nurse should first stay with the client and use a calm, low-pitched voice to promote safety and reduce anxiety levels. Severe anxiety impairs cognitive processing, making it impossible for the client to learn new skills or analyze triggers at this stage. Non-pharmacological presence and a soothing environment are the immediate priorities before considering medication or education.
美國 NCLEX 強調『Therapeutic Presence』（治療性陪伴）作為獨立護理功能；台灣臨床環境節奏快，護理師往往傾向於先給予 PRN 藥物以快速穩定病房秩序，而非花長時間留在床邊陪伴。