— 心理社會完整性 · EASY · MCQ —
一位診斷為重度憂鬱症的病人入院，哪項護理措施應列為優先？
A client is admitted to the psychiatric unit with a diagnosis of severe depression. Which nursing intervention is the priority?
- AMonitor the client's nutritional and fluid intake.監測客戶的營養與液體攝取量
- BAssess the client's risk for self-harm or suicide.✓ 正解評估客戶自我傷害或自殺的風險
- CAssist the client with activities of daily living.協助客戶進行日常生活活動
- DEncourage the client to participate in group therapy.鼓勵客戶參與團體治療
— Explanation · 中文詳解 —
對於重度憂鬱症病人，安全是首要考量。護理師必須評估其是否有自殺意念、計劃或手段。雖然營養、日常活動和團體治療都很重要，但若病人不安全，其他介入措施均無意義。這是 NCLEX 中處理精神科病人的黃金法則：Safety First（安全第一）。
Safety is the highest priority for clients with severe depression due to the significant risk of suicide. The nurse must immediately assess for suicidal ideation, intent, and plan before addressing other needs such as nutrition or social interaction. Ensuring the client's physical safety is the foundational step that allows for all other therapeutic interventions to be effective.
✦ 台美臨床差異
美國 NCLEX 考試極度強調 Suicide Assessment 的標準化流程；台灣臨床則常由家屬陪住來分擔監測責任。