— 心理社會完整性 · MEDIUM · MCQ —
一位病人因性侵害被送至急診，哪項護理措施為最高優先級？
A client is brought to the emergency department after a sexual assault. Which nursing intervention is the highest priority?
- ADocument the client's physical injuries in detail詳細記錄病人的身體創傷
- BPerform a head-to-toe physical assessment進行全身身體評估
- CEnsure the client's safety and provide a supportive environment✓ 正解確保病人安全並提供支持性環境
- DContact the sexual assault nurse examiner (SANE)聯繫性侵害護理專員（SANE）
— Explanation · 中文詳解 —
心理安全與受害者身心支持是性侵害護理的首要任務。在急性期，建立信任關係並確保病人脫離再次傷害的威脅最為重要。詳細記錄與檢體採集雖然重要，但在確保病人感受到安全與被同理之前，不宜倉促進行以免造成二度創傷。
Establishing a safe, supportive environment is the highest priority to prevent further trauma and build the therapeutic rapport necessary for care. Ensuring physical and emotional safety precedes detailed documentation or forensic examinations, which can be distressing if performed prematurely.
✦ 台美臨床差異
美國多設有專門的 SANE 系統；台灣則多由急診科醫師與社工師協同處理，護理師角色較偏向危機處置。