護理師評估一位憂鬱症住院病患，下列哪些指標顯示其自我傷害風險最高？（選所有適合的）
A nurse is performing a risk assessment for a client who has been hospitalized for depression. Which indicators place the client at the highest risk for self-harm? (Select all that apply.)
- AThe client has a specific plan and the means to carry it out.✓ 正解個案有具體計畫且具備執行手段
- BThe client expresses feelings of hopelessness and worthlessness.個案表達無望感與無價值感
- CThe client gives away prized personal possessions.✓ 正解個案贈送珍貴個人物品
- DThe client reports a sudden improvement in mood and increased energy.✓ 正解個案報告情緒突然改善且精力增加
- EThe client avoids social interaction with other patients.個案避免與其他病患互動
自殺風險評估的關鍵在於「意圖、計畫、工具」與「行為改變」。擁有明確計畫與工具（A）、變賣或給予貴重物品（C）、以及情緒突然變好（D，可能意指已下定決心結束生命），皆為高危險訊號。B與E是憂鬱症常見症狀，但不如上述指標直接反映自殺行為風險。
The keys to suicide risk assessment are intent, plan, means, and behavioral changes. Having a specific plan and means (A), giving away or selling valuables (C), and a sudden lift in mood (D, possibly indicating that the person has firmly decided to end their life) are all high-risk warning signs. B and E are common symptoms of depression, but they do not directly reflect suicide risk as clearly as the indicators mentioned above.
美國採取嚴格的自殺風險評估流程；台灣醫院則多依賴護理師的臨床敏銳度觀察與紀錄。