# 對於一位情緒低落長達六週的成人，護理師在社會心理評估中應包含哪些行動？（請選出所有合適的選項）

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375137&lang=zh-tw  
> language: zh-TW  
> subject: Management of Care  
> category: MOC

## 題目

對於一位情緒低落長達六週的成人，護理師在社會心理評估中應包含哪些行動？（請選出所有合適的選項）

1

篩檢可能擬似或加重憂鬱之物質使用(SBIRT、AUDIT、DAST)

2

避免詢問自殺念頭以免植入觀念

3

執行PHQ-9並關注第9題之自傷念頭

4

紀錄社會決定因素 — 居住、糧食安全、社會支持、財務

5

若PHQ-9第9題陽性,使用C-SSRS等已驗證自殺評估

## 解析

USPSTF 建議使用 PHQ-9（B 級建議）進行成人憂鬱症篩檢；其中第 9 題特別篩檢死亡/自傷念頭，若回答為陽性則觸發完整的自殺風險評估，如使用 C-SSRS 或類似工具。物質使用篩檢同樣重要，因為酒精、大麻、類鴉片藥物可能模仿或加重憂鬱症狀。社會決定因素影響健康結果。詢問自殺意念並不會增加自殺風險——這是一個已被證據推翻的常見迷思；直接、冷靜地詢問其實具有保護作用。

## 深入解析

PHQ-2為2題篩檢,陽性接PHQ-9。憂鬱篩檢應並行物質與創傷篩檢。自殺篩檢陽性記錄計畫、手段、意圖。

## 臨床情境

42歲新病人。失樂感、睡眠差、疲勞。無精神科病史。

## 重要概念

- **PHQ-9** — 9題憂鬱嚴重度工具,含第9題自殺念頭篩檢。
- **C-SSRS** — 哥倫比亞自殺嚴重度量表 — 結構化自殺風險評估。
- **健康之社會決定因素** — 影響健康之環境條件:經濟、教育、居住、社會脈絡。

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