— 心理社會完整性 · MEDIUM · MCQ —
護理師正在與一位因配偶過世而經歷哀傷的病人一同工作。病人說：「我無法想像沒有他們的生活，我看不見繼續下去的意義。」何為首要的護理介入措施？
A nurse is working with a client who is experiencing grief after the loss of a spouse. The client states, 'I can't imagine life without them. I don't see the point of going on.' What is the priority nursing intervention?
- AEncourage the client to talk about their memories of the spouse.鼓勵個案談論關於配偶的回憶
- BSuggest joining a grief support group.建議加入哀傷支持團體
- CHelp the client develop a daily schedule.協助個案制定每日行程表
- DExplore the client's suicidal ideation and ensure safety.✓ 正解探索個案的自殺意念並確保安全
— Explanation · 中文詳解 —
在 NCLEX 考試中，安全（Safety）永遠是護理優先級（Prioritization）中的最高原則。病人提到「看不見繼續下去的意義」是典型的自殺意念（Suicidal Ideation）警訊。護理師必須立即評估自殺計畫與危險性，並採取預防措施，確保病人處於安全環境中，這是護理介入的絕對優先級。
The priority nursing intervention is to explore the client's suicidal ideation and ensure safety, as statements like 'I don't see the point of going on' are red flags for suicide risk. While reminiscing and support groups are beneficial, assessing for immediate danger and implementing safety measures is the highest priority in nursing care.