— 心理社會完整性 · EASY · MCQ —
精神科病房的個案表達了自我傷害的想法。為了確保個案安全，護理師的首要行動為何？
A client on the psychiatric unit expresses thoughts of self-harm. Which action is the priority for the nurse to ensure client safety?
- AAdminister PRN anxiolytic medication給予處方備用抗焦慮藥物
- BInitiate one-to-one observation✓ 正解實施一對一監護
- CAsk the client to sign a 'no-harm' contract請個案簽署『無傷害』合約
- DRestrict all visitors to prevent negative triggers限制所有探視以預防負面觸發因素
— Explanation · 中文詳解 —
當個案表達自殺意念，維護安全是最高指導原則。一對一觀察（One-to-one observation）是目前實證醫學中防止自殺最直接有效的方法。合約雖可作為一種治療性工具，但不能取代物理性的安全監測。藥物僅為輔助，不能保證個案不會採取行動。
One-to-one observation provides constant supervision, which is the most effective evidence-based method to prevent immediate self-harm when a client expresses suicidal ideation. While medications and contracts have roles in treatment, they do not guarantee safety or replace the need for direct monitoring.
✦ 台美臨床差異
美台皆採一對一觀察。台灣醫療環境中，依據評估分級（Suicide Precautions）會更強調環境安全檢查。