— 心理社會完整性 · MEDIUM · MCQ —
一位 45 歲患有廣泛性焦慮症的病人，出現呼吸急促、發抖及面臨災難的感覺。護理師應採取的第一項措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents with rapid breathing, trembling, and a feeling of impending doom. Which action is the priority for the nurse?
- AAdminister the prescribed PRN anxiolytic medication給予處方之備用抗焦慮藥物
- BInstruct the client to breathe into a paper bag指示病人用紙袋呼吸
- CEncourage the client to discuss the source of their anxiety鼓勵病人討論其焦慮來源
- DStay with the client and use a calm, firm, low-pitched voice✓ 正解陪伴病人並使用平靜、堅定、低沉的聲音
— Explanation · 中文詳解 —
面對急性焦慮發作，護理師應提供安全、穩定的環境。陪伴病人並以冷靜、低沉的語氣對話能有效降低其恐慌感，這是護理的第一要務。B選項使用紙袋呼吸已非目前建議（恐引發二氧化碳蓄積）；A選項雖可減緩症狀，但在確認病人生理狀態前，優先建立治療性關係與安撫更重要；C選項在病人高度焦慮時無法進行認知討論。
During an acute anxiety attack, the priority is to provide a safe, stable environment to help contain the client's panic. Staying with the client and using a calm, firm, low-pitched voice effectively reduces fear and promotes de-escalation. While medication may be needed later, establishing a therapeutic presence is the immediate nursing intervention.
✦ 台美臨床差異
美國護理常強調主動陪伴與環境治療；台灣臨床較依賴醫師開立之鎮靜藥物作為急性緩解手段。