— 心理社會完整性 · HARD · MCQ —
一位 20 歲憂鬱症患者服用 SSRI 藥物兩週。護理師最優先的評估項目為何？
A 20-year-old client with major depressive disorder has been on an SSRI for 2 weeks. Which assessment is the highest priority for the nurse?
- ACompliance with medication dosage藥物劑量的順從性
- BFrequency of social interactions社交互動的頻率
- CImprovement in appetite and sleep patterns食慾與睡眠模式的改善
- DPresence of suicidal ideation✓ 正解是否存在自殺意念
— Explanation · 中文詳解 —
SSRI 藥物起效通常需 2-4 週，然而在初期階段，病人的生理能量（如精神、動作遲緩改善）可能先於情緒改善恢復，這增加了病人實施自殺行為的風險。因此，這段期間評估自殺意念（Suicidal Ideation）是維護病人生命安全的最優先要務。
SSRIs typically require 2-4 weeks to take effect. However, in the early phase of therapy, the patient's physical energy (e.g., improvements in psychomotor retardation) may recover before mood improves, which increases the risk that the patient will act on suicidal impulses. For this reason, assessing suicidal ideation during this period is the highest priority for safeguarding the patient's life.
✦ 台美臨床差異
美台臨床皆重視自殺評估，台灣針對高風險病人有完善的通報與關懷機制，護理師需熟悉個案的自殺防範計畫。