— 心理社會完整性 · MEDIUM · MCQ —
護理師照護一位親密伴侶暴力受害者。哪項評估發現是最高優先級？
A nurse is providing care for a survivor of intimate partner violence. Which assessment finding is the highest priority?
- AVerbal reports of frequent crying spells口頭報告經常哭泣
- BFeelings of shame and guilt regarding the abuse對遭受虐待感到羞恥和內疚
- CReports of inability to sleep報告無法入睡
- DStatements indicating a plan for suicide✓ 正解表示有自殺計畫的陳述
— Explanation · 中文詳解 —
在護理照護中，評估的優先順序遵循 ABC（氣道、呼吸、循環）原則及病人安全。親密伴侶暴力（Intimate Partner Violence, IPV）受害者常伴隨複雜的身心壓力，但任何涉及「自殺計畫」的陳述，代表病人正處於立即性的生命威脅中，必須優先處理。自殺風險評估與危機介入是護理師照護所有心理健康病人的最高優先級，旨在防止自傷行為發生。其他情緒症狀雖需關注，但均屬次要。
Safety is always the highest priority in psychosocial assessment. An IPV survivor expressing a suicide PLAN is an immediate life-threatening emergency requiring crisis intervention—line of sight observation, removal of means, mental health/psychiatric consult, and safety planning. Crying, insomnia, and guilt/shame are common emotional sequelae and require supportive intervention but are not immediately life-threatening.