護理師照護一位剛使用抗憂鬱藥的重度憂鬱症個案，哪些症狀應立即回報醫師？（選所有適合的）
A nurse is caring for a client with major depressive disorder who has started a new antidepressant. Which symptoms should the nurse report to the provider? (Select all that apply.)
- ANew onset of suicidal ideation✓ 正解新出現自殺意念
- BIncreased energy level with persistent insomnia✓ 正解活動力增加伴隨持續失眠
- CMild dry mouth輕微口乾
- DDevelopment of extreme agitation or restlessness✓ 正解出現極度激動或不安
- EOccasional vivid dreams偶爾做生動的夢
抗憂鬱藥物（特別是選擇性血清素回收抑制劑，SSRIs）在治療初期，個案能量提升但情緒仍未改善，這段「能量差距」可能增加自殺計畫與執行力，屬於高危險期。此外，極度激動或失眠可能是藥物誘發躁症（Manic switch）或嚴重副作用（如靜坐不能 Akathisia）的跡象。護理師必須對這類行為變化高度警覺，這屬於心理安全（Psychosocial Integrity）範疇內的優先評估項目。
During the initial phase of antidepressant therapy (especially with selective serotonin reuptake inhibitors, SSRIs), a patient's physical energy may improve before their mood does; this 'energy gap' can increase the patient's ability to plan and carry out suicide and represents a high-risk period. In addition, extreme agitation or insomnia may signal medication-induced mania (manic switch) or serious adverse effects such as akathisia. The nurse must remain highly alert to these behavioral changes, which are priority assessments within the domain of psychosocial integrity.
在美國臨床環境中，針對自殺風險評估有嚴格的標準化量表（如 C-SSRS），一旦出現 A 或 B 選項狀況，護理師通常需立即啟動「自殺防護措施（Suicide Precautions）」，並透過電子病歷系統（EMR）即時通知醫師與相關心理衛生團隊。