— 心理社會完整性 · MEDIUM · MCQ —
一位剛喪偶的年長病人表示：「我不知道起床還有什麼意義。」護理師首要的評估是什麼？
A nurse is caring for an older adult who recently lost a spouse. The client states, 'I just don't see the point of waking up anymore.' Which assessment is the priority?
- AAssess the client's sleep patterns and appetite評估病人的睡眠模式與食慾
- BEncourage the client to join a support group鼓勵病人參加支持團體
- CAdminister an antidepressant as ordered by the provider依醫囑給予抗憂鬱劑
- DAsk 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
— Explanation · 中文詳解 —
當病人表達出絕望感（如「不知道起床還有什麼意義」），護理師必須執行「自殺風險評估」。自殺意念（Suicidal Ideation）是心理衛生護理中最高優先級的議題。護理師必須直接詢問病人是否有明確的自殺計畫（Plan），以決定是否需要立即啟動安全監護（如 1:1 觀察）。安全高於一切，其他治療計畫均需在確保生命安全後再進行。
When a client expresses hopelessness ("I don't see the point of waking up"), the nurse must perform a suicide risk assessment. Suicidal ideation is the highest priority in psychiatric nursing. Directly asking whether the client has a specific plan determines whether 1:1 safety monitoring is needed. Safety supersedes all else; other interventions follow only after life is secured.