— 心理社會完整性 · MEDIUM · SATA —
護理師正在評估一位重度憂鬱症的個案，下列哪些發現是預期中的？（選所有適合的）
A nurse is interviewing a client diagnosed with major depressive disorder. Which findings are expected during the assessment? (Select all that apply.)
- AAnhedonia✓ 正解快感缺失
- BPsychomotor agitation or retardation✓ 正解精神運動性激越或遲滯
- CFlight of ideas思維奔逸
- DInsomnia or hypersomnia✓ 正解失眠或嗜睡
- EFeelings of worthlessness or excessive guilt✓ 正解無價值感或過度罪惡感
— Explanation · 中文詳解 —
重度憂鬱症診斷標準包含情緒低落、喪失興趣（Anhedonia）、體重改變、睡眠障礙、精神運動遲滯或激動、疲憊、無價值感與自殺意念。飛行思想（Flight of ideas）屬於躁鬱症躁期特徵，非憂鬱症症狀。護理師評估時須特別注意自殺風險評估。
DSM criteria for major depressive disorder include depressed mood, loss of interest (anhedonia), weight change, sleep disturbance, psychomotor agitation or retardation, fatigue, feelings of worthlessness, and suicidal ideation. Flight of ideas is characteristic of manic episodes, not depression. The nurse should pay special attention to suicide-risk assessment.
✦ 台美臨床差異
台美對憂鬱症篩檢工具（如 PHQ-9）使用一致，但台灣臨床護理師常需額外協助家屬理解憂鬱症為生理疾病，而非單純心情不佳。