護理師照顧一位有自殘行為的邊緣型人格障礙個案。優先的護理介入為何？
A nurse is caring for a client with borderline personality disorder who is exhibiting self-mutilating behaviors. What is the priority nursing intervention?
- APlace the client in one-to-one observation將客戶置於一對一觀察下
- BEnsure the client's physical wounds are assessed and treated✓ 正解確保客戶的身體傷口已接受評估與治療
- CExplore the underlying emotional cause of the self-mutilation探討自殘行為背後的情緒原因
- DInitiate a no-suicide contract with the client與客戶建立無自殺契約
面對自殘行為，護理的基本準則永遠是「安全第一」。必須先評估並處理實質的身體損傷，確保傷口處理完畢且無生命威脅。合約（D）在臨床實證中對防止自殺無顯著效果；探索原因（C）是後續心理治療重點；觀察（A）則需視風險程度而定，優先次序皆在身體穩定後。
When faced with self-mutilating behaviors, the fundamental nursing rule is always "safety first." The nurse must first assess and manage the actual physical injuries, ensuring wounds are treated and there is no immediate threat to life. No-suicide contracts (option D) have not been shown to be effective in preventing suicide; exploring the underlying cause (option C) is the focus of subsequent psychotherapy; observation (option A) depends on the level of risk, and all of these have lower priority than physical stabilization.
台美臨床對於自殘者的傷口處理無異，但美國更傾向強調治療聯盟，台灣則傾向醫囑下的嚴格管制。