— 心理社會完整性 · HARD · SATA —
護理師照顧一位呈現憂鬱症狀的個案，下列哪些症狀需立即回報醫療團隊？（選所有適合的）
A nurse is caring for a client who is exhibiting signs of depression. Which of the following symptoms should the nurse report to the healthcare provider immediately? (Select all that apply.)
- AThe client mentions they are 'tired of fighting' and just want to sleep forever✓ 正解個案表示他們『厭倦了掙扎』，只想永遠睡著
- BThe client has been giving away their personal belongings✓ 正解個案正在贈送其個人財物
- CThe client reports sleeping 10 hours per night個案報告每晚睡眠 10 小時
- DThe client expresses feeling hopeless about the future個案表達對未來感到絕望
- EThe client has formulated a specific plan to end their life✓ 正解個案已擬定結束生命的具體計畫
— Explanation · 中文詳解 —
憂鬱症個案若出現自殺意念、自殺計畫或告別式行為（送貴重物品），屬於自殺危險度高的紅旗指標，必須立即執行自殺防範措施與評估。睡眠 10 小時與無望感是憂鬱的常見臨床表現，需持續觀察但非最緊急的自殺風險。
Statements indicating a desire to sleep forever, giving away personal belongings, and formulating a specific suicide plan are high-risk indicators of imminent self-harm that require immediate intervention. While increased sleep and hopelessness are common symptoms of depression, they do not constitute an acute emergency compared to active suicidal ideation and planning.
✦ 台美臨床差異
台灣法律與臨床對於自殺防範需填寫嚴格的『自殺危險評估表』，護理師責任重大。