個案對護理師說：「我覺得我活不下去了，一切都太沉重了。」護理師應優先採取何種措施？
A client states to the nurse, 'I don't think I can go on living anymore; everything is just too much.' Which action should the nurse take first?
- ANotify the physician immediately立即通知醫師
- BEncourage the client to talk about their feelings鼓勵個案談論其感受
- CPlace the client in a room with constant observation將個案安置於需持續觀察的房間
- DAssess the client for a suicide plan and lethality✓ 正解評估個案是否有自殺計畫及其致命性
面對自殺意念的個案，護理師的首要任務是進行風險評估（Suicide Risk Assessment）。在任何後續處置（如通知醫師、安排觀察）之前，必須先釐清個案的自殺計畫（Plan）、意圖（Intent）及致死性（Lethality），以判斷其立即危險程度。這是護理評估的關鍵步驟，能決定後續是否需要啟動緊急醫療應對或採取保護性隔離措施。直接評估自殺計畫不僅能收集重要臨床資料，也能向個案展現護理師對其感受的重視，建立治療性溝通的基礎。
For a client expressing suicidal ideation, the nurse's first priority is to perform a suicide risk assessment. Before any subsequent intervention (such as notifying the physician or arranging observation), the client's plan, intent, and lethality must be clarified to determine the level of immediate danger. This is a key step in nursing assessment, determining whether emergency medical response or protective isolation must be initiated. Directly assessing the suicide plan not only gathers crucial clinical data but also conveys to the client that the nurse takes their feelings seriously, establishing the foundation for therapeutic communication.