— 心理社會完整性 · EASY · MCQ —
一位 45 歲患有廣泛性焦慮症的病人出現心跳過快、顫抖及瀕死感。護理師應優先採取哪項護理措施？
A 45-year-old client with a history of generalized anxiety disorder presents with a rapid heart rate, trembling, and a feeling of impending doom. Which intervention is the highest priority for the nurse?
- AAdminister an as-needed benzodiazepine給予處方箋劑量的苯二氮平類藥物
- BEncourage the client to talk about the cause of the anxiety鼓勵病人談論焦慮的原因
- CPerform a physical assessment to rule out cardiac issues進行身體評估以排除心臟問題
- DInstruct the client to breathe deeply and slowly✓ 正解指示病人深呼吸並放慢速度
— Explanation · 中文詳解 —
面對焦慮症狀，首要目標是降低焦慮程度。呼吸技巧能活化副交感神經，幫助生理層面放鬆。病人處於高焦慮狀態時，無法進行深度溝通（B），應先穩定情緒。藥物（A）需醫囑且為輔助手段，物理評估（C）雖重要，但需先緩解急性期症狀。
Instructing the client to breathe deeply and slowly is the highest priority as it activates the parasympathetic nervous system to reduce physiological arousal. While assessment and medication are relevant, calming the acute anxiety response takes precedence when the client is unable to engage in complex tasks. This simple technique helps stabilize the client's condition immediately.
✦ 台美臨床差異
美國護理師常依護理標準程序指引教導呼吸技巧；台灣護理人員亦會教導，但臨床常較依賴醫師評估後給予鎮靜藥物。