— 心理社會完整性 · HARD · MCQ —
護理師在精神科急性病房工作，下列哪項評估發現需要立即通知醫師？
A nurse is working in an inpatient psychiatric unit. Which assessment finding requires immediate notification of the healthcare provider?
- AThe client reports a belief that food is being poisoned個案表示相信食物被下毒
- BThe client refuses to participate in scheduled group therapy個案拒絕參加排定的團體治療
- CThe client is observed pacing in the hallway個案被觀察到在大廳踱步
- DThe client has made a specific threat to harm a staff member✓ 正解個案已做出傷害護理人員的具體威脅
— Explanation · 中文詳解 —
在精神科護理中，人身安全為最高原則。選項 D 明確指出對他人有攻擊威脅，這屬於暴力潛在風險，須立即採取預防措施如隔離、監護或藥物介入。選項 A 是妄想症狀，C 為焦慮表現，B 為拒絕治療，均屬需持續評估但非立即緊急狀況。
Safety is the highest priority in psychiatric nursing. A specific threat to harm a staff member indicates an imminent risk of violence, requiring immediate intervention such as isolation or medication to ensure patient and staff safety. While delusions, refusal of therapy, and agitation are significant concerns, they do not constitute an immediate emergency comparable to a direct threat of harm.
✦ 台美臨床差異
美國法規對 Duty to Warn 強度高；台灣精神衛生法對於潛在暴力評估標準亦趨嚴格。