— 心理社會完整性 · EASY · MCQ —
一位客戶向護理師表示：「我不想活了，我計畫今晚結束生命。」護理師應優先採取何種措施？
A nurse is interviewing a client who states, 'I do not want to live anymore; I have a plan to end it all tonight.' Which action is the priority for the nurse?
- ACall the client's family members to come to the hospital通知病人家屬來醫院
- BContract with the client to not harm themselves for 24 hours與病人簽訂24小時內不傷害自己的協議
- CEnsure the client is placed under constant observation for safety✓ 正解確保病人接受持續看護以保障安全
- DDocument the statement in the medical record將此陳述記錄於病歷中
— Explanation · 中文詳解 —
自殺危機處理的首要目標是「生命安全」。當客戶有明確計畫與意圖時，持續觀察（1對1看護）能直接阻斷其傷害自己的機會。B選項契約法已不再被視為自殺預防的黃金標準；A選項需考量隱私；D選項屬書面記錄，不能替代安全保護措施。
The first goal in managing a suicide crisis is to ensure the client's safety. When a client has a clear plan and intent, constant observation (one-to-one supervision) directly blocks the opportunity to inflict self-harm. Option B is no longer considered the gold standard for suicide prevention; option A requires consideration of privacy; option D is documentation and cannot replace actual safety protection.
✦ 台美臨床差異
美國醫院常見 'Sitter' 制度；台灣常需依賴家屬輪流看護，資源差異顯著。