— 心理社會完整性 · HARD · MCQ —
護理師正在照護一位表達自殺意念的重度憂鬱症病人，護理師最需要獲取的評估資料是什麼？
A nurse is caring for a client with major depressive disorder who is expressing suicidal ideation. Which is the MOST critical assessment data for the nurse to obtain?
- AThe client's sleep patterns.個案的睡眠模式
- BThe presence of a specific plan, intent, and means.✓ 正解是否存在具體計畫、意圖與手段
- CThe client's current mood state.個案目前的情緒狀態
- DThe client's history of previous suicide attempts.個案既往自殺未遂史
— Explanation · 中文詳解 —
評估自殺風險的首要考量是病人是否有具體的自殺計畫、意圖以及可獲得的手段 (means)。這些因素能最直接地反映出近期自殺的可能性。雖然情緒狀態（C）和過往病史（D）也很重要，但具體計畫和意圖是判斷立即風險的關鍵。
The most critical assessment for a client expressing suicidal ideation is determining the presence of a specific plan, intent, and means. While mood and history are relevant, these three factors provide the most direct indication of immediate suicide risk and urgency.
✦ 台美臨床差異
在評估自殺風險時，美台護理師都強調評估計畫、意圖和手段。美國的臨床指引可能更強調使用結構化的自殺風險評估工具。