一位 45 歲焦慮症病人表示感到絕望。護理師在初始評估時應優先採取什麼行動？
A 45-year-old client diagnosed with generalized anxiety disorder expresses feelings of hopelessness. Which intervention should the nurse prioritize during the initial assessment?
- AEncourage the client to practice deep breathing鼓勵病人練習深呼吸
- BTeach the client about the physiology of anxiety教導病人關於焦慮的生理機制
- CAdminister an ordered anxiolytic medication給予處方的抗焦慮藥物
- DAssess for the presence of suicidal ideation✓ 正解評估是否有自殺意念
當病人表達絕望感（Feelings of hopelessness）時，護理師必須優先評估安全。絕望感通常是憂鬱症與自殺意念（Suicidal ideation）的強烈預測因子。在初始評估中，必須直接詢問病人是否有傷害自己的念頭，這不會引發自殺，反而能提供病人表達的出口並進行必要的安全防護。其他介入措施如深呼吸、藥物或衛教，皆應在確保病人生命安全無虞後才執行。
When a patient expresses feelings of hopelessness, the nurse must prioritize safety. Hopelessness is a strong predictor of depression and suicidal ideation. During the initial assessment, the nurse must directly ask whether the patient has thoughts of self-harm. Doing so does not provoke suicide; rather, it provides the patient an outlet for expression and allows necessary safety measures to be initiated. Other interventions such as deep breathing, medication, or education should only be implemented after the patient's safety has been ensured.