— 心理社會完整性 · HARD · SATA —
一位重度憂鬱症個案表示：「活著已經沒有意義了。」護理師應採取哪些措施？（選所有適合的）
A client experiencing severe depression says, 'There is no point in living anymore.' Which actions should the nurse take? (Select all that apply.)
- AConduct a formal suicide risk assessment✓ 正解進行正式的自殺風險評估
- BPlace the client on one-to-one observation✓ 正解將病人安置於一對一觀察
- CRemove harmful objects from the client's reach✓ 正解移除病人可及範圍內的有害物品
- DOffer false reassurance that things will get better給予事情會變好的虛假保證
- EDocument the client's statement verbatim✓ 正解逐字記錄病人的陳述
— Explanation · 中文詳解 —
當個案表達自殺意念時，護理師必須將其視為最高危險等級（highest priority），並採取立即的安全保護措施。評估致命性（assessment）、移除危險源（safety）、一對一觀察（observation）及詳實紀錄（documentation）是護理師在處理自殺危機時的標準作業流程（standard of care）。
When a client expresses suicidal ideation, the nurse must prioritize immediate safety by conducting a formal suicide risk assessment, placing the client on one-to-one observation, and removing potentially harmful objects from the environment. Additionally, documenting the client's statements verbatim provides essential clinical evidence for ongoing care and legal protection.