對於呈現嚴重憂鬱症狀的病人，哪些護理措施是適當的？（選所有適合的）
Which of the following are appropriate nursing interventions for a client exhibiting signs of severe depression? (Select all that apply.)
- AConduct a formal suicide risk assessment✓ 正解進行正式的自殺風險評估
- BEncourage the client to set small, manageable goals✓ 正解鼓勵個案設定小型且可管理的目標
- CAvoid discussing the client's feelings to prevent further sadness避免討論個案的感受以防加重悲傷
- DProvide a safe, structured environment✓ 正解提供安全且結構化的環境
- EEnsure the client takes medications as prescribed✓ 正解確保個案按處方服藥
嚴重憂鬱症（Severe Depression）個案的護理核心為維持安全與建立治療性關係。自殺風險評估是臨床第一優先，能幫助護理師判斷監控等級；結構化的環境可減少個案因認知功能受損而產生的混亂與焦慮；設定小目標能協助個案在無助感中重建掌控感與自信；遵從藥物治療則是改善生理性神經傳導物質失衡的基礎。護理師應主動引導個案表達情緒，而非迴避。
Prioritizing suicide risk assessment is critical for ensuring client safety in severe depression. Providing a structured environment and setting small, manageable goals helps reduce anxiety and rebuild self-esteem. Ensuring medication adherence supports physiological stabilization, while actively encouraging emotional expression remains therapeutic rather than avoiding it.
在美國臨床，護理師需具備高度敏銳度執行自殺篩檢工具（如 Columbia-Suicide Severity Rating Scale），若評估高風險，必須立即啟動個別監控（1:1 Sitter），此執行強度在美國法規要求下極為嚴格。