— 心理社會完整性 · MEDIUM · SATA —
護理師照顧一位表達自殺意念的病人，哪項行動最能優先維護安全？（選所有適合的）
A nurse is caring for a client who expresses suicidal ideation. Which of the following actions demonstrates the highest level of priority for safety? (Select all that apply.)
- AConduct a one-to-one observation✓ 正解實施一對一觀察
- BRemove all potential self-harm items from the room✓ 正解移除房間內所有潛在的自我傷害物品
- CEncourage the client to journal their feelings鼓勵病人以日記記錄感受
- DPerform a formal risk assessment✓ 正解進行正式的風險評估
- EAssign a private room far from the nursing station安排遠離護理站的私人病房
— Explanation · 中文詳解 —
自殺意念病人的首要原則是環境安全與嚴密監控。連續性觀察（1:1）可即時介入；移除危險物品防止突發自我傷害；風險評估用於擬定照護等級。日記雖有抒發功能，但非急性安全措施。隔離病人於遠處會降低監控可見度。
The top priorities for a client with suicidal ideation are environmental safety and close monitoring. Continuous one-to-one observation allows for immediate intervention; removing dangerous items prevents sudden self-harm; and risk assessment is used to determine the level of care. Although journaling can be therapeutic, it is not an acute safety measure. Placing the client in an isolated room far away reduces visibility for monitoring.
✦ 台美臨床差異
台灣醫院自殺評估多採用特定量表與強制住院機制，美國則更強調預測模型。