— 心理社會完整性 · MEDIUM · MCQ —
一位剛喪偶的年長者對護理師表示：「我真的覺得沒必要再吃飯或起床了。」護理師應優先評估下列何者？
A nurse is caring for an older adult who recently lost a spouse. The client states, 'I just don't see the point in eating or getting out of bed anymore.' Which assessment finding should the nurse prioritize?
- AThe client's nutritional intake for the past week過去一週病人的營養攝取量
- BThe presence of a plan or intent for self-harm✓ 正解是否存在自我傷害的計畫或意圖
- CThe client's ability to perform activities of daily living病人執行日常生活活動的能力
- DThe client's relationship with surviving family members病人與倖存家屬的關係
— Explanation · 中文詳解 —
個案表達出對生活失去動力與意義，這是憂鬱症及自殺意念的高風險表現。護理優先順序以維護生命安全為首，故必須優先評估是否有自殺計畫或意圖。日常活動功能與營養狀況雖重要，但在排除個案有自我傷害風險之前，安全評估應置於第一優先。
The nurse's role in informed consent is to witness the client's signature and verify that the client is competent and signing voluntarily. It is the physician's legal responsibility to explain the procedure, risks, benefits, and alternatives. The nurse does not determine the medical necessity of the surgery or override the patient's autonomous decision-making process.
✦ 台美臨床差異
美國護理師在評估自殺風險時使用標準化量表（如 CSSRS）；台灣臨床護理評估傾向口頭詢問，量表使用普及率較低。