護理師評估一位嚴重憂鬱症病人的自殺風險。下列哪些發現表示需優先介入？（選所有適合的）
A nurse is performing a suicide risk assessment on a client with severe depression. Which findings indicate the highest priority for intervention? (Select all that apply.)
- AThe client has a specific plan and means✓ 正解病患有具體計畫與手段
- BThe client expresses feelings of hopelessness✓ 正解病患表達絕望感
- CThe client has a history of past attempts✓ 正解病患有過去嘗試紀錄
- DThe client reports sleeping 10 hours a night病患報告每晚睡眠10小時
- EThe client gives away prized possessions✓ 正解病患贈送珍貴物品
自殺風險評估的關鍵在於計畫的可行性、過去嘗試史以及絕望感。擁有明確計畫與工具（A）為最高危險；絕望感（B）是預測自殺的強力因子；過去嘗試史（C）顯著增加未來風險；送出心愛物品（E）是常見的告別行為。睡眠增多（D）雖與憂鬱相關，但非急性自殺危險指標。
The key to suicide risk assessment lies in the feasibility of the plan, history of previous attempts, and feelings of hopelessness. Having a specific plan and the means to carry it out (A) confers the highest risk; hopelessness (B) is a strong predictor of suicide; a history of previous attempts (C) significantly increases future risk; and giving away cherished belongings (E) is a common farewell behavior. Hypersomnia (D), although associated with depression, is not an acute indicator of suicide risk.
美國醫院有標準化評估量表（如 Columbia-Suicide Severity Rating Scale）；台灣臨床對自殺評估也逐漸採用類似標準，但更依賴醫師的臨床判斷。