護理師為嚴重憂鬱症的個案進行自殺風險評估。個案哪一句話顯示出最高風險？
A nurse is performing a suicide risk assessment for a client who is severely depressed. Which statement by the client indicates the highest level of risk?
- AI have been thinking about how I would end it all using my medication.✓ 正解我一直在想如何用我的藥物來結束一切。
- BI feel like there is no point in living anymore.我覺得活著已經沒有意義了。
- CEverything feels so hopeless and dark lately.最近一切都感覺如此絕望和黑暗。
- DMy family would be better off without me.如果沒有我，我的家人會過得更好。
在自殺風險評估中，護理師必須依照「意念（Ideation）、計畫（Plan）、方法（Method）」的層級來判斷危險性。僅僅表達情緒上的無望感或死亡意念雖然需要關注，但若個案已經擬定具體的執行計畫，且取得或準備了致死工具，其自殺的迫切性與危險程度最高。選項 A 指出了明確的手段與方式，顯示個案已具備執行能力，屬於高風險層級。
A specific suicide plan involving available lethal means, such as the client's medication, indicates the highest level of immediate risk. While feelings of hopelessness and passive suicidal ideation are concerning, the presence of a concrete method and intent signifies a greater likelihood of action. Immediate safety interventions and psychiatric evaluation are required for clients expressing active plans.
在美國臨床環境中，若評估出個案有具體計畫（Plan）與方法（Means），護理師須立即執行 'Suicide Precautions' 或 'Safety Watch'，並聯繫醫師與精神科會診，這與台灣的評估標準一致，但美國法規對 'Duty to Warn' 的執行更為嚴謹。