病人表達自殺想法。護理師首要任務為何？
A client expresses suicidal thoughts. What is the nurse's first priority?
- AAssess the risk by asking if they have a plan✓ 正解透過詢問是否有計畫來評估風險
- BDocument the statement in the chart and wait for the doctor將陳述記錄於病歷並等待醫師
- CContact the family to warn them immediately立即聯繫家人警告他們
- DEnsure the patient is never left alone確保病人絕不單獨一人
面對表達自殺意念（Suicidal ideation）的病人，護理師的首要任務是進行自殺風險評估（Risk assessment）。在NCLEX的臨床判斷模型中，優先級別通常遵循ABC（Airway, Breathing, Circulation）或安全優先原則。評估病人是否具備具體的自殺計畫（Plan）、手段（Means）及意圖（Intent），能協助護理師判斷自殺的迫切性（Immediacy），進而決定是否需要立即啟動自殺防範措施（Suicide precautions），如一對一觀察（1:1 observation）。選項A是執行安全照護的第一步。
When a client expresses suicidal ideation, the nurse's first priority is a suicide risk assessment. Under the NCLEX clinical judgment model, prioritization typically follows the ABC (Airway, Breathing, Circulation) framework or the safety-first principle. Assessing whether the client has a specific plan, means, and intent enables the nurse to determine the immediacy of suicide risk and decide whether suicide precautions, such as 1:1 observation, should be initiated. Option A is the first step in delivering safe care.
美國法律對於「Duty to Warn」有嚴格規定，若病人有明確傷害他人或自己的意圖，護理師有法律責任通報。台灣在精神科照護上，針對自殺評估的標準流程與美國高度一致，但美國護理師在法律層面需更強調對病人隱私與通報義務之間的權衡。