— 心理社會完整性 · MEDIUM · MCQ —
一位 45 歲憂鬱症病人表示：「我是家人的累贅，沒有我他們會過得更好。」護理師的首要行動為何？
A 45-year-old client diagnosed with depression states, 'I am a burden to my family, and they would be better off without me.' What is the nurse's priority action?
- AEncourage the client to talk about positive life experiences鼓勵病人談論積極的生活經驗
- BAsk the client if they have a plan to harm themselves✓ 正解詢問病人是否有傷害自己的計畫
- CNotify the family to take the client home通知家屬將病人接回家
- DDocument the statement in the medical record在病歷中記錄該陳述
— Explanation · 中文詳解 —
面對出現絕望感與自殺意念的病人，評估自殺計畫的具體性是預防傷害的第一優先。此言論屬於自殺警訊，必須立即釐清風險層級。C 會加重風險；C 此時無法有效建立同理連結；D 是必要紀錄但非緊急處置優先級最高者。
When dealing with a patient who expresses hopelessness and suicidal ideation, assessing the specificity of the suicide plan is the first priority for preventing harm. Such statements are a suicide warning sign and the level of risk must be clarified immediately. B will worsen the risk; C cannot effectively establish an empathic connection at this moment; D is necessary documentation but is not the highest priority emergency action.
✦ 台美臨床差異
台美臨床皆將自殺風險評估視為首要，但在台灣，護理師通常需同時聯繫精神科醫師進行強制評估。