— 心理社會完整性 · MEDIUM · MCQ —
在憂鬱症病人的評估中，護理師應將下列哪項發現視為優先處置項目？
Which of the following findings in a client with depression should the nurse identify as a priority for intervention?
- AStatements of hopelessness and having a plan for suicide✓ 正解表達絕望感並有自殺計畫
- BDifficulty concentrating on simple tasks難以集中注意力於簡單任務
- CLoss of interest in hobbies對嗜好失去興趣
- DExcessive sleeping during the day白天過度睡眠
— Explanation · 中文詳解 —
憂鬱症照護中，安全永遠是最高原則（ABC 原則）。當病人表達絕望感且有自殺計畫時，代表其存在立即性的生命威脅，護理師須立即啟動自殺防範措施。其他症狀（失眠、興趣減退、注意力不集中）雖是憂鬱症的常見臨床表現，但優先級低於自殺風險評估。
Safety is the highest priority in nursing care; therefore, statements of hopelessness combined with a specific suicide plan represent an immediate life-threatening emergency. The nurse must initiate suicide precautions immediately, whereas other symptoms like difficulty concentrating or loss of interest, while significant, do not pose an imminent risk to life.
✦ 台美臨床差異
台美皆採取自殺風險篩檢（如PHQ-9）；在美國，護理師具備高度自主權啟動自殺防護觀察，台灣則需醫師醫囑同步確認。