護理師為一名重度憂鬱症個案進行自殺風險評估。下列哪些徵象顯示有立即的安全性風險？（選所有適合的）
A nurse is performing a suicide risk assessment on a client with major depressive disorder. Which findings indicate an immediate risk to safety? (Select all that apply.)
- AThe client states, 'I have a plan to end my life tomorrow.'✓ 正解案主表示：『我有一個明天結束生命的計畫。』
- BThe client has started giving away personal belongings.✓ 正解案主開始贈送個人財物。
- CThe client reports sleeping 10 hours a night for the past week.案主報告過去一週每晚睡 10 小時。
- DThe client has sudden improvement in mood and energy.✓ 正解案主的情緒和精力突然改善。
- EThe client states that they feel hopeless and worthless.案主表示他們感到絕望和無價值。
自殺風險評估需重視計畫具體性、資源放棄行為與情緒變化。計畫明確（A）、贈送貴重物品（B）為高風險行為。特別是當憂鬱症病人突然顯得心情變好（D），可能是因為已經決定自殺而感到解脫，這是極度危險的徵兆。反之，睡眠增加（C）或表達無望感（E）是憂鬱症狀，但不如上述三項直接連結自殺動機。
Suicide risk assessment must take into account the specificity of the plan, behaviors involving giving away possessions, and changes in mood. A specific plan (A) and giving away valuables (B) are high-risk behaviors. In particular, when a client with depression suddenly appears markedly improved in mood (D), it may be because they have decided to commit suicide and feel a sense of relief, an extremely dangerous sign. In contrast, increased sleep (C) or expressions of hopelessness (E) are depressive symptoms but are less directly linked to suicidal motivation than the three behaviors above.
美國護理常規中使用標準化的自殺風險評估工具（如 C-SSRS），台灣臨床多依賴資深護理師的臨床直覺與會談評估。