護理師正在照護一位有自殺嘗試史的病人。病人表達了無價值感和絕望感。下列何者需要護理師立即介入？
A nurse is caring for a client with a history of suicide attempts. The client expresses feelings of worthlessness and hopelessness. Which of the following requires IMMEDIATE nursing intervention?
- AClient states, 'I feel like a burden to my family.'病人表示：「我覺得自己是家人的負擔。」
- BClient states, 'I can't stand this pain anymore.'病人表示：「我再也受不了這種痛苦了。」
- CClient states, 'Nothing matters anymore.'病人表示：「一切都無關緊要了。」
- DClient states, 'I have a plan to end my life tonight.'✓ 正解病人表示：「我計劃在今晚結束自己的生命。」
當病人明確表示有具體的自殺計畫（D），例如「今晚結束生命」，這構成了最高的即時風險，需要立即採取行動，包括進一步評估計畫、意圖、手段，並啟動安全措施。A、B、C 句也表達了負面感受，但 C 句包含了具體的行動計畫，風險最高。
When a patient explicitly states a specific suicide plan (D) — for example, "I will end my life tonight" — this represents the highest level of imminent risk and requires immediate action, including further assessment of the plan, intent, and means, and activation of safety measures. Options A, B, and C also express negative feelings, but option D includes a concrete action plan, which carries the highest risk.
在面對病人表達自殺意念時，美台護理師都將有具體計畫的病人視為最高風險。美國在自殺防治的應急措施和介入流程上可能更為細緻。