# 一位強迫症個案在根據約定的暴露與反應預防計畫延遲洗手儀式時，變得高度焦慮。護理師應採取何項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=498095&lang=zh-tw  
> language: zh-TW  
> subject: Mental Health Concepts  
> category: PSI

## 題目

一位強迫症個案在根據約定的暴露與反應預防計畫延遲洗手儀式時，變得高度焦慮。護理師應採取何項行動？

## 選項

1. 解釋所擔心的事件不會發生，並讓個案獨自控制想法
2. 承認焦慮，並在延遲儀式時指導約定的因應技巧 **✔ 正確答案**
3. 每當焦慮開始上升時，無限制地允許洗手儀式
4. 告訴個案該儀式是不理性的，並堅持今天立即停止

**正確答案: 2**

## 解析

暴露與反應預防刻意將計畫好的觸發因子與支持性的延遲或預防強迫行為配對。護理師應確認個案的痛苦，並指導治療計畫中已建立的因應策略，而不提供保證或突然放棄計畫。

## 深入解析

快速解答
保持支持，說出焦慮，並在延遲儀式時指導約定的因應技巧。這遵循計畫好的暴露與反應預防方法。

為什麼這是正確的
強迫行為短暫減輕焦慮，因此強化強迫意念與強迫行為的循環。在支持性練習中忍受焦慮而不完成儀式，可使痛苦在沒有強迫行為的情況下下降，並建立對不同反應的信心。

簡單比喻或心智圖像
儀式就像一條捷徑，暫時緩解焦慮，但讓相同的迴圈持續。暴露與反應預防練習留在較安全的路徑上，直到焦慮下降；此類比並不意味著暴露應在個人化計畫外即興或強迫進行。

記憶掛鉤
說出焦慮，遵循約定的暴露計畫，指導因應，不餵養儀式。

NCLEX 決策規則
當暴露與反應預防已開立時，支持個案度過計畫中的焦慮，不給予保證、嘲笑或無限制地完成儀式。不要獨立地將暴露強度增加到超過約定的治療計畫。

為什麼其他選項是錯的
邏輯保證無法停止侵入性想法，且可能成為循環的一部分。無限制地完成儀式強化強迫行為，而對質和強迫立即停止可能增加痛苦並損害信任。參考文獻

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]NIMH: Obsessive-Compulsive DisorderNational Institute of Mental Health

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