面對嚴重憂鬱的病人，護理師應優先評估哪些事項？（選所有適合的）
Which assessment findings should the nurse prioritize in a client with severe depression? (Select all that apply.)
- APresence of a suicide plan and lethal means✓ 正解是否存在自殺計畫與致命工具
- BChanges in sleep patterns and appetite睡眠模式與食慾的變化
- CRecent sudden improvement in mood✓ 正解近期情緒突然改善
- DVerbal statements of hopelessness✓ 正解表達絕望的言語
- EHistory of childhood physical abuse童年遭受身體虐待的病史
嚴重憂鬱病人若出現自殺意念（計畫與工具）、絕望感，以及突然的心情改善（可能代表決定執行自殺計畫），均為極高風險指標。雖然睡眠與食慾改變（B）也是憂鬱症狀，但相較於立即性的致命自殺風險，非優先順序。童年虐待史（E）是風險因子，但非當下致命性評估的急迫點。
In a patient with severe depression, the presence of suicidal ideation (plan and means), hopelessness, and a sudden improvement in mood (which may indicate that the patient has decided to act on a suicide plan) are extremely high-risk indicators. Although changes in sleep patterns and appetite (option B) are also symptoms of depression, they are lower priority compared with imminent life-threatening suicide risk. A history of childhood abuse (option E) is a risk factor but is not an urgent priority in current life-safety assessment.
美國採取嚴格的自殺風險評估量表（如 C-SSRS）；台灣醫療環境常因時間壓力，對自殺動機的深入探討較為受限。