— 心理社會完整性 · HARD · MCQ —
一位憂鬱症病人表示：「我沒什麼好活的了，如果我走了，一切都會更好。」護理師應優先執行哪項評估？
A client admitted for depression states, 'I have nothing to live for, and everything will be better if I am gone.' Which assessment should the nurse perform first?
- AAssess the client for a specific suicide plan✓ 正解評估病人是否有具體的自殺計畫
- BReview the client's medication adherence history檢視病人的用藥順從性歷史
- CInquire about the client's support system詢問病人的支持系統
- DAsk the client about their current living situation詢問病人目前的生活狀況
— Explanation · 中文詳解 —
當病人表達出自殺意念，評估自殺計畫的具體性、致死性與取得工具的便利性（即計畫、手段、時間表）是護理師的優先任務，這是評估自殺風險最重要的依據。D、C、B 雖是重要的評估內容，但比起即刻生命威脅，優先級較低。
When a patient expresses suicidal ideation, evaluating the specificity, lethality, and accessibility of the plan (i.e., plan, means, and timeline) is the nurse's priority and the most important basis for assessing suicide risk. D, C, and B are also important assessments, but compared with the immediate threat to life, they are lower priority.
✦ 台美臨床差異
台美均嚴格執行自殺風險評估，美國醫院有嚴謹的 Columbia-Suicide Severity Rating Scale 標準化流程要求。