一位22歲男性大學生在一場近乎致命的服藥過量自殺未遂後，於三天前被收治入院至封閉精神科病房，診斷為重度憂鬱症 (MDD)。這幾天他都安靜地在房間內隔離自己。今天早晨，他突然走出房門，看起來異常開朗放鬆，將他最愛的復古手錶送給了室友，並平靜地對護理師說：「謝謝你們為我做的一切。我終於想通了所有的問題，現在覺得無比輕鬆。一切都會在今晚徹底解決。」護理師必須積極執行哪些立即的護理介入？（多選題）
A 22-year-old male college student was admitted to the inpatient psychiatric unit three days ago following a nearly fatal overdose attempted suicide amidst a diagnosis of Major Depressive Disorder (MDD). He had been isolating in his room silently. This morning, he suddenly emerges, appears exceptionally cheerful and relaxed, gives away his favorite vintage watch to a roommate, and peacefully tells the nurse, "Thank you for everything. I've finally figured out all my problems, and I feel so light. Everything will be completely resolved by tonight." Which immediate nursing interventions must be aggressively implemented? (Select all that apply.)
- ADocument a positive nursing progress note reflecting the successful onset of action of his new antidepressant medications.撰寫正面護理進度紀錄，反映新抗憂鬱藥物已開始發揮作用
- BPlace the client immediately on strict one-to-one (1:1) continuous visual observation within arm's length.立即對個案實施嚴格的一對一（1:1）持續視覺觀察，保持在伸手可及範圍內正確答案
- CAsk the client directly and bluntly, "Are you having thoughts of killing yourself tonight?"直接且坦率地詢問個案：「你今晚是否有自殺念頭？」正確答案
- DSearch the client's room thoroughly for stockpiled pills, sharpened objects, or improvised ligatures (e.g., shoelaces).徹底搜尋個案房間，查找囤積的藥丸、尖銳物品或臨時製成的束縛物（例如鞋帶）正確答案
- EInform the client comfortably that he will likely be discharged tomorrow morning since his crisis is visibly resolved.安撫個案，告知其危機已明顯解除，預計明天早上即可出院
- B立即對個案實施嚴格的一對一（1:1）持續視覺觀察，保持在伸手可及範圍內
- C直接且坦率地詢問個案：「你今晚是否有自殺念頭？」
- D徹底搜尋個案房間，查找囤積的藥丸、尖銳物品或臨時製成的束縛物（例如鞋帶）
本題測驗極度危險的精神科特徵：自殺意念（Suicidal Ideation）的偽裝性好轉。當嚴重憂鬱或有近期自殺史的患者，出現「突發性的情緒好轉」、「表現出平靜」並伴隨「分發財產／道別（Giving away possessions / Saying goodbyes）」時，這並非康復，而是他們已經做出了堅定且極具殺傷力的「自殺決定」。一旦決定赴死，內在的心理衝突與折磨消失，因而產生虛假的安詳。護理師絕不能將此視為藥量起效的好轉現象（選項A錯誤）。為防止病患「今晚」的自殺規劃，必須立刻啟動最高防護：指派專人對其實施 24小時無死角的 1對1（1:1）近距離視覺監視（選項B正確）。不畏避諱，必須直接、坦率且清晰地（Directly and bluntly）詢問病患當下是否有自殺的念頭或具體計畫，這不會引發自殺，反而能核實危機（選項C正確）。徹底搜查房間以沒收所有可用於上吊、吞食或割腕的潛在利器及物品也是標準防護的必須行為（選項D正確）。選項E的提早出院將直接導致病患於院外致死。
- A撰寫正面護理進度紀錄，反映新抗憂鬱藥物已開始發揮作用
有自殺傾向的病患突然、劇烈的情緒好轉象徵著一個即將發生且已成形的自殺計畫帶來了情緒的解脫，而非治療性藥物的療效。
- B · 正確答案立即對個案實施嚴格的一對一（1:1）持續視覺觀察，保持在伸手可及範圍內
在極度豐富的警告跡象下，一隻手臂距離內的持續 1:1 監視是在物理層面上防止自我傷害的絕對臨床標準。
- C · 正確答案直接且坦率地詢問個案：「你今晚是否有自殺念頭？」
直接詢問自殺計畫是一個令人不適但強制必要的最佳實踐；它能精準評估致命意圖，且絕不會將自殺的想法植入他們的腦中。
- D · 正確答案徹底搜尋個案房間，查找囤積的藥丸、尖銳物品或臨時製成的束縛物（例如鞋帶）
既然病患暗示了事件將在『今晚』發生，就必須積極地將環境中所有潛在的致命手段清空。
- E安撫個案，告知其危機已明顯解除，預計明天早上即可出院
讓一個表現出經典『暴風雨前寧靜』跡象且正活躍企圖自殺的病患出院，是一項極其災難性的重大臨床過失。
「突然情緒變好＝做好了赴死決定」這點全球精神衛生界都將之視為防範金律。在考題上，必須堅定選擇問出不委婉的句子：你是不是打算殺了你自己？（Are you going to kill yourself ?）
English explanation
A sudden, unexplained improvement in mood in a severely depressed client with recent suicidal behavior often signals that the client has made a firm decision to attempt suicide, removing their internal conflict. Immediate safety measures include placing the client on strict one-to-one observation, directly asking about suicidal intent, and thoroughly searching the environment for potential means of self-harm. Discharging the client or documenting this as a positive response to medication would be dangerous and negligent.
最近修訂：2026-10-06