— 心理社會完整性 · HARD · MCQ —
一位 25 歲女性個案因近期分手向護理師表示感到「毫無價值」與「沒用」。護理師應優先採取何種回應？
A 25-year-old female client tells the nurse that she feels 'worthless' and 'useless' following a recent breakup. Which response should the nurse prioritize?
- AYou are a capable person with much to offer你是一個有能力且能貢獻很多的人
- BLet's focus on positive things in your life讓我們專注於你生活中的美好事物
- CHave you thought about hurting yourself?✓ 正解你有想過傷害自己嗎？
- DIt is normal to feel sad after a breakup分手後感到悲傷是正常的
— Explanation · 中文詳解 —
當個案表達自我價值低落或無用感時，護理師必須首先評估自殺風險。即使僅是口頭抱怨，也不能排除其潛在的自我傷害意圖。D 選項是輕描淡寫；A 選項為過早的安慰（False Reassurance）；B 選項則是轉移焦點。優先進行自殺評估是護理安全的核心。
When a client expresses feelings of low self-worth or uselessness, the nurse must first assess the risk for suicide. Even when these are only verbal complaints, the possibility of an underlying intent to self-harm cannot be ruled out. Option D minimizes the feelings; option A provides false reassurance; option B shifts the focus. Prioritizing suicide assessment is the cornerstone of nursing safety.
✦ 台美臨床差異
美國護理教育極度強調自殺風險評估的啟動時機，台灣臨床則在評估量表的使用上近年也趨向嚴謹。