— 心理社會完整性 · MEDIUM · SATA —
護理師為患有重度憂鬱症且出現社交退縮的個案規劃護理措施，應包含哪些內容？（選所有適合的）
Which of the following interventions should a nurse include when planning care for a client who has been diagnosed with major depressive disorder and is experiencing social withdrawal? (Select all that apply.)
- AEstablish a consistent, non-demanding presence✓ 正解建立穩定且無壓力的陪伴
- BEncourage participation in group therapy immediately鼓勵立即參與團體治療
- CProvide positive reinforcement for small accomplishments✓ 正解對微小成就提供正向增強
- DEnsure safety through frequent observation✓ 正解透過頻繁觀察確保安全
- ESet realistic, short-term goals for activity participation✓ 正解設定活動參與的現實且短期的目標
— Explanation · 中文詳解 —
對於社交退縮的憂鬱症個案，護理介入重點在於建立信任與循序漸進。強制參與團體治療（B）會造成壓力並強化退縮行為。非強制性的陪伴能建立安全感，透過正向強化與設定短期目標，能提升個案的自我效能感，同時安全評估是照護的核心。
Care for a socially withdrawn client with major depressive disorder should focus on building trust through a consistent, non-demanding presence and setting realistic, short-term goals. Positive reinforcement for small accomplishments helps improve self-esteem, while frequent observation ensures safety from potential suicidal ideation.
✦ 台美臨床差異
美國強調個案參與決策過程；台灣臨床環境有時因護理人力受限，較難做到一對一的長時間陪伴。