長照機構內一位高齡病人坐在公共區域哭泣，表示：「我只是這裡每個人的負擔，我真希望就這樣睡著再也不要醒來。」護理師的首要行動為何？
An elderly client in a long-term care facility is found crying in the common area. The client states, 'I'm just a burden to everyone here. I wish I could just sleep and never wake up.' What is the nurse's priority action?
- AReassure the client that they are valued and not a burden to the staff.安慰個案，表示其受到重視且不是護理人員的負擔。
- BAsk the client directly if they are having thoughts of harming themselves.✓ 正解直接詢問個案是否有傷害自己的念頭。
- COffer the client a warm beverage and encourage them to join a group activity.提供個案一杯熱飲，並鼓勵其參加團體活動。
- DDocument the client's statement and monitor their behavior every shift.記錄個案的陳述，並在每個班次監測其行為。
當病人表達出「希望不要醒來」或「負擔感」等言語時，護理師必須高度懷疑自殺意念（Suicidal Ideation）。在精神科與心理社會照護中，「評估安全性」永遠是第一優先。最正確、最直接的方法就是「直接詢問」。很多人誤以為詢問會「提醒」病人自殺，但臨床研究證明，直接詢問能讓病人感到被理解，並提供獲救的機會。選項 B 直接評估風險，是啟動後續安全預防措施的前提。其他選項（如 D、C、A）雖然也有幫助，但都忽略了當下最緊迫的安全評估，屬於避重就輕的作法。護理師必須具備直接面對死亡話題的勇氣與專業素養。
When a patient expresses statements such as "I wish I could just sleep and never wake up" or a sense of being a burden, the nurse must have a high index of suspicion for suicidal ideation. In psychiatric and psychosocial care, "assessing safety" is always the first priority. The most appropriate and direct approach is to ask directly. Many people mistakenly believe that asking about suicide may "plant the idea" in the patient's mind, but clinical research has shown that direct questioning makes patients feel understood and provides an opportunity for them to receive help. Option B directly assesses risk and lays the groundwork for implementing safety precautions. The other options (D, C, A) may be helpful but neglect the most pressing immediate safety assessment and avoid the heart of the issue. The nurse must have the courage and professional competence to confront topics related to death directly.
美國 NCLEX 考試中，遇到自殺警訊必須選擇「直接詢問（Direct questioning）」；台灣臨床上護理師可能較委婉，或傾向先通報醫師由醫師詢問，但在護理專業職權上，護理師應具備獨立評估自殺風險的能力。