管理有自殺意念的病人時，護理師應優先執行哪項措施？（選所有適合的）
Which of the following actions should the nurse prioritize when managing a client with potential suicidal ideation? (Select all that apply.)
- ARemove all potentially dangerous items from the room✓ 正解移除房間內所有潛在危險物品
- BAssign a staff member to sit with the client at all times✓ 正解指派工作人員全程陪伴病人
- CAsk the client directly if they have a plan to hurt themselves✓ 正解直接詢問病人是否有傷害自己的計畫
- DWait for the client to bring up their feelings about suicide等待病人主動提出關於自殺的感受
- EDocument the client's behavior and statements verbatim✓ 正解逐字記錄病人的行為和言論
針對自殺風險病人，安全性是最高原則。直接詢問（C）不會誘發自殺，反而能評估嚴重性；移除危險物品（A）與採取一對一密切觀察（B）是環境控制的核心。詳細記錄（E）是法律與照護傳承的關鍵。選項 D 錯誤，護理師必須主動出擊，不可被動等待。
For clients at risk of suicide, safety is the highest priority. Asking directly (C) does not provoke suicide; rather, it allows the nurse to assess severity. Removing dangerous objects (A) and one-to-one close observation (B) are the core elements of environmental control. Thorough documentation (E) is critical for legal protection and continuity of care. Option D is incorrect because the nurse must take an active approach and not wait passively.
美國法規對於自殺風險的監控標準極為嚴格（如 Joint Commission 要求）；台灣臨床則依賴護理師的臨床直覺與病房空間設計。