— 心理社會完整性 · EASY · MCQ —
病人表達自殺意念。護理師應優先採取哪項行動？
A client expresses suicidal ideation. Which priority action should the nurse take?
- ADiscuss the potential causes of the suicidal thoughts.討論自殺念頭的可能原因
- BAsk the client if they have a plan.✓ 正解詢問個案是否有具體計畫
- CDocument the statement in the medical record.在病歷中記錄該陳述
- DPlace the client in a private room for observation.將個案安置於私人房間觀察
— Explanation · 中文詳解 —
當病人表達自殺意念時，護理師的首要任務是進行風險評估（Risk assessment）。評估是否具備「自殺計畫（Suicidal plan）」、手段的可及性及致死性，是決定病人安全等級的關鍵。這項評估必須在第一時間完成，以啟動相應的自殺防範計畫（Suicide precautions），這比文書作業或探討病因更為緊急。
When a client expresses suicidal ideation, the nurse's first priority is risk assessment. Evaluating whether the client has a suicidal plan, the accessibility of means, and the lethality of the plan is critical for determining the client's safety level. This assessment must be completed immediately so that appropriate suicide precautions can be initiated, which is more urgent than documentation or exploring underlying causes.