— 心理社會完整性 · HARD · SATA —
對於診斷為憂鬱症且表達自殺意念的病人，下列哪些護理措施是適當的？（選所有適合的）
Which of the following interventions are appropriate for a client diagnosed with depression and expressing suicidal ideation? (Select all that apply.)
- APlace the client on one-to-one observation✓ 正解將案主置於一對一監護下
- BRemove all sharp objects and potentially dangerous items from the room✓ 正解移除房間內所有尖銳物品及潛在危險物品
- CEncourage the client to socialize with other patients to distract them鼓勵案主與其他病患社交以轉移注意力
- DFrequently assess the client for changes in mood or energy levels✓ 正解經常評估案主的情緒或能量水平變化
- EEnsure the client swallows all medication by checking the mouth✓ 正解檢查口腔以確保案主吞下所有藥物
— Explanation · 中文詳解 —
自殺預防首重環境安全與視線不離開。一對一觀察（1:1）是防止自殺的標準作法。移除危險品是基礎安全措施。密切監測情緒突變是必要的，因為能量突然提升可能是病人計畫執行自殺的徵兆。確認服藥則可防止病人藏藥企圖自殺。
Suicide prevention prioritizes environmental safety and continuous visual contact. One-to-one observation (1:1) is the standard approach for preventing suicide. Removing dangerous items is a basic safety measure. Close monitoring for sudden mood changes is essential because a sudden surge in energy may signal that the client has decided to act on a suicide plan. Verifying medication ingestion prevents the client from hoarding pills to attempt suicide.
✦ 台美臨床差異
台灣病房常依賴護理站視線或監視器，但對於高風險病人，仍應依醫囑執行高強度看護。