護理師評估客戶是否有自殺傾向。哪些敘述或觀察應促使護理師進一步評估風險？（選所有適合的）
A nurse is assessing a client for signs of suicidal ideation. Which statements or observations should prompt the nurse to further evaluate the risk? (Select all that apply.)
- AThe client reports giving away cherished personal belongings✓ 正解個案報告將珍愛之個人物品贈送他人
- BThe client experiences a sudden elevation in mood✓ 正解個案經歷情緒突然升高
- CThe client expresses a sense of hopelessness✓ 正解個案表達無望感
- DThe client begins to sleep for 8 hours every night個案開始每晚睡眠8小時
- EThe client mentions 'I won't be around to worry about this much longer'✓ 正解個案提及『我不會再長久留在此處為此煩惱了』
自殺評估需高度警覺警訊，包含分配財產（準備結束）、絕望感（動力消失）、言語暗示。值得注意的是「心情突然轉好」，常發生在決定結束生命後的短暫平靜感。睡眠改善則多為正向指標，非自殺風險，除非伴隨其他反常行為。
Suicide assessment requires heightened vigilance for warning signs, including giving away possessions (preparing for the end), hopelessness (loss of motivation), and verbal cues. Of note, a 'sudden improvement in mood' often occurs as a brief calm after the decision to end life has been made. Improved sleep is usually a positive indicator and is not a suicide risk unless accompanied by other atypical behaviors.
美國醫院對自殺風險評估有嚴格的 Universal Screening 流程；台灣臨床則多依賴精神科照會及護理師主觀評估。