一位家暴受害者個案，護理師評估發現哪項發現最需緊急處理？
A nurse is assessing a client who has been a victim of domestic violence. Which assessment finding is most concerning and requires immediate intervention?
- AFear of the abuser coming to the facility.害怕施暴者到訪醫療機構。
- BBruises in various stages of healing.各階段癒合的瘀傷。
- CA statement saying, 'I am worthless and deserve this.'表示『我毫無價值，活該遭受這種對待。』
- DThe client expresses a plan to harm themselves.✓ 正解案主表達傷害自己的計畫。
在評估受虐個案時，護理師必須區分一般的心理壓力與立即的生命威脅。雖然身體損傷（瘀青）與低自我價值感是受虐的常見徵兆，但「明確的自殺計畫」構成即刻的生命危險（Safety Priority）。依據 ABC（Airway, Breathing, Circulation）與安全性原則，護理師必須優先處理威脅生命的安全問題，即刻啟動自殺風險防範，確保病患不受到傷害。
When assessing a victim of abuse, the nurse must distinguish general psychological distress from immediate threats to life. Although physical injury (bruising) and low self-worth are common signs of abuse, a clearly articulated plan to harm oneself constitutes an immediate threat to life (a safety priority). Based on ABC (airway, breathing, circulation) and safety principles, the nurse must address life-threatening safety issues first by initiating suicide-risk precautions and ensuring the client is protected from harm.
在美國，若護理師評估到病患有自殺意念或計畫，通常會啟動「1:1 Constant Observation」，甚至會將病患轉移至精神科安全病房。此外，針對家暴（Domestic Violence），護理師在美國需負有「強制通報（Mandatory Reporting）」的法律責任。