一位診斷為重度憂鬱症的病人入住精神科病房。優先的護理干預措施為何？
A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. What is the priority nursing intervention?
- AMonitor for suicidal ideation and safety✓ 正解監測自殺意念與安全
- BEncourage participation in group therapy鼓勵參與團體治療
- CAssessing the client's sleeping patterns評估病人的睡眠模式
- DTeaching the client about medication side effects教導病人關於藥物副作用
對於診斷為重度憂鬱症（Major Depressive Disorder）的病人，護理師的首要任務是確保其安全。重度憂鬱症病人因情緒低落、絕望感、無價值感或無助感，自殺風險極高。因此，無論在任何情況下，評估自殺意念（suicidal ideation）並採取相應的安全措施都是護理的最高優先級。其他干預措施雖然重要，但必須建立在病人安全無虞的基礎上。護理師應持續觀察病人的情緒變化、行為表現和言語表達，並與醫療團隊密切合作，共同制定和執行自殺預防計畫。
For a client diagnosed with major depressive disorder (MDD), the nurse's first priority is to ensure safety. Clients with MDD have a very high suicide risk due to depressed mood, hopelessness, worthlessness, or helplessness. Therefore, in any situation, assessing for suicidal ideation and implementing appropriate safety measures is the highest nursing priority. Other interventions, while important, must be built on the foundation of patient safety. The nurse should continuously observe the client's mood changes, behavior, and verbal expression and work closely with the medical team to develop and implement a suicide prevention plan.
在美國和台灣，對於重度憂鬱症病人的照護，確保病人安全，特別是評估和預防自殺，都是精神科護理的最高優先級。此臨床思路與優先順序在全球範圍內均為標準實踐，無顯著差異。護理師應始終將病人安全置於首位。