一位憂鬱症個案入院,下列哪種觀察發現需要護理師立即介入?
A client is admitted for major depressive disorder. Which observation requires the nurse’s immediate attention?
- AThe client refuses to eat breakfast病人拒絕吃早餐
- BThe client expresses a desire to be alone病人表示想獨處
- CThe client gives away personal belongings to other patients✓ 正解病人將個人物品贈送給其他病人
- DThe client stares at the wall for hours病人盯著牆壁數小時
憂鬱症個案的照護重點在於評估自殺風險。當個案開始將個人物品分贈他人,這是一個高度危險的行為警訊,象徵個案正在進行「交代後事(making final arrangements)」,顯示其自殺計畫已具備具體性與迫切性。護理師必須依據護理過程(Nursing Process),在發現此類行為時,立即啟動自殺風險評估,採取必要的安全防範措施(如一對一觀察),確保個案安全。
Care for a client with depression centers on assessing suicide risk. When the client begins to give away personal belongings to others, this is a highly dangerous behavioral warning, symbolizing that the client is 'making final arrangements' and indicating that the suicide plan has become concrete and urgent. Based on the nursing process, the nurse must immediately initiate a suicide risk assessment upon noticing such behavior and implement necessary safety precautions (such as one-to-one observation) to ensure the client's safety.