— 心理社會完整性 · HARD · MCQ —
護理師評估一位重度憂鬱症個案，下列哪項發現為最高優先順序？
Which assessment finding is the highest priority for the nurse evaluating a client with major depressive disorder?
- APoor personal hygiene個人衛生不良
- BFlat affect and social withdrawal情感平淡與社交退縮
- CInsomnia and early morning awakening失眠與清晨早醒
- DStatements about wanting to die✓ 正解表達想死的言論
— Explanation · 中文詳解 —
在精神科評估中，「安全」永遠是第一優先。重度憂鬱症個案若出現自殺意念或意圖（Statements about wanting to die），代表個案處於生命危險狀態，需立即啟動自殺防護機制（如一對一觀察、移除危險物品）。其他症狀如個人衛生差、睡眠障礙皆為疾病表現，雖需治療，但急迫性遠低於自殺意念。
In psychiatric nursing, safety is always the highest priority. Statements about wanting to die indicate suicidal ideation, which poses an immediate threat to life and requires urgent intervention, such as initiating suicide precautions. While poor hygiene, social withdrawal, and insomnia are common symptoms of major depressive disorder, they are not as immediately life-threatening as active suicidal thoughts.