— 心理社會完整性 · HARD · SATA —
護理師為新入院病人進行自殺風險評估，哪些敘述需要立即處理？（選所有適合的）
A nurse is performing a risk assessment for suicide on a new inpatient. Which client statements require immediate intervention? (Select all that apply.)
- AI don't think I can make it through the weekend✓ 正解我想我撐不過這個週末了
- BMy family would be better off without me✓ 正解我家裡人沒有我會比較好過
- CI have been feeling really depressed lately我最近感覺真的很抑鬱
- DI have decided on a way to end the pain✓ 正解我已經決定要結束這種痛苦的方式了
- EI am looking forward to my discharge我很期待出院
— Explanation · 中文詳解 —
自殺風險評估（Suicide risk assessment）是心理衛生護理的重點。具體計畫（Specific plan，選項 D）、無望感（Hopelessness，選項 A）、認為沒有自己家人會更好（負面價值感，選項 B）皆為高危險警訊，代表病人不僅有自殺念頭，且可能已準備執行。護理師必須立即啟動防自殺機制（如一對一看護、移除危險物品、通知精神科醫師），以確保病人安全。
Statements indicating a specific plan, hopelessness, or feelings of being a burden signal high immediate suicide risk. These cues require urgent intervention, such as initiating one-to-one observation and removing potential means of self-harm. General depression or positive discharge plans do not indicate the same level of imminent danger.