對於表現出重度憂鬱及自殺意念的個案，下列哪些護理措施是適當的？（選所有適合的）
Which of the following interventions are appropriate for a client exhibiting symptoms of severe depression and suicidal ideation? (Select all that apply.)
- AImplementing 1:1 observation at all times✓ 正解實施全天候 1:1 監護
- BPlacing the client in a private room far from the nurses' station將病患安置在遠離護理站的單人病房
- CConducting frequent environmental checks to remove sharp objects✓ 正解頻繁進行環境檢查以移除尖銳物品
- DEncouraging the client to keep their feelings to themselves to avoid stress鼓勵病患將感受藏在心裡以避免壓力
- EAssessing for a specific suicide plan and intent✓ 正解評估是否有具體的自殺計畫與意圖
自殺風險高的個案首重安全防護，包含一對一監控、移除危險物品（銳器、繩索等）及評估自殺意念強度與計畫細節。選項 B 錯誤：應放在護理站附近以便觀察；選項 D 錯誤：應鼓勵個案表達情緒，壓抑情緒會增加衝動行為風險。
For clients at high risk for suicide, safety protection is the top priority and includes one-to-one observation, removal of dangerous items (sharp objects, cords, etc.), and assessment of the strength and details of suicidal ideation and plans. Option B is incorrect: the client should be placed near the nurses' station for easier observation. Option D is incorrect: the client should be encouraged to express their emotions, because suppressing them increases the risk of impulsive behavior.
美國醫院有明確的自殺防護標準流程與量表；台灣在自殺個案處理上更仰賴精神科醫師診斷與家屬簽署切結書，護理師角色較為執行面。