— 心理社會完整性 · EASY · MCQ —
一位 45 歲患有廣泛性焦慮症的病人因手術入院。護理師觀察到病人正來回踱步且過度換氣。護理師首要介入措施為何？
A 45-year-old client with a history of generalized anxiety disorder is admitted for surgery. The nurse notes the client is pacing and hyperventilating. Which intervention is the priority?
- AAssist the client with deep breathing exercises協助病人進行深呼吸運動
- BAdminister the PRN dose of anxiolytic medication給予處方標示必要時（PRN）使用的抗焦慮藥物
- CEncourage the client to discuss their fears about the surgery鼓勵病人討論對手術的恐懼
- DMaintain a calm, quiet, and low-stimulation environment✓ 正解維持安靜、平靜且低刺激的環境
— Explanation · 中文詳解 —
面對急性焦慮症狀，首要目標是降低環境刺激以防止焦慮升級。環境控制能提供心理安全感，幫助病人自我調節。藥物介入（B）應在初步嘗試降低刺激與協助呼吸技巧（A）無效後進行。討論恐懼（C）應在焦慮緩解後才進行，否則可能增加病人壓力。
The priority intervention for a client experiencing acute anxiety is to reduce environmental stimuli to prevent escalation and promote self-regulation. Maintaining a calm, quiet setting addresses the immediate physiological arousal, whereas pharmacological interventions or exploring underlying fears are secondary steps taken after initial stabilization.
✦ 台美臨床差異
美國護理師在環境調整上較有自主權；台灣病房環境通常較吵雜，且護理師多依醫囑先行給藥。