— 心理社會完整性 · MEDIUM · MCQ —
護理師照顧一位剛喪偶的個案，個案表示：「我看不到繼續活下去的理由。」護理師應如何回應？
A nurse is caring for a client who recently lost a spouse. The client states, 'I don't see any reason to keep living.' Which response by the nurse is most appropriate?
- AHave you thought about how you would harm yourself?✓ 正解你有想過要如何傷害自己嗎？
- BWhy do you feel that way?你為什麼會有這種感覺？
- CEverything will get better with time.隨著時間過去，一切都會好轉的。
- DYou have family members who love you very much.你有非常愛你的家人。
— Explanation · 中文詳解 —
面對表達自殺意念的個案，護理師的首要任務是評估其安全性。自殺意念（suicidal ideation）的評估必須包含三個層次：意念、計畫與手段。直接詢問個案是否有傷害自己的具體計畫或手段，不僅是評估危險性的關鍵步驟，也能傳達護理師願意傾聽並正視其痛苦的態度。錯誤選項多屬於治療性溝通中的禁忌，如給予廉價承諾或追問「為什麼」，容易讓個案感到被拒絕或產生防衛心理。
The nurse must directly assess for suicidal intent and plan when a client expresses hopelessness, as this is critical for ensuring patient safety. Non-therapeutic responses like asking "why," offering false reassurance, or minimizing feelings fail to address the immediate risk and may increase defensiveness.