護理師對憂鬱症患者進行精神狀態評估，哪些發現顯示自殺風險高？（選所有適合的）
A nurse is performing a mental status examination on a client with severe depression. Which findings indicate the client is at high risk for suicide? (Select all that apply.)
- AThe client gives away prized possessions✓ 正解病人將珍貴物品送人
- BThe client expresses a sudden sense of peace after a long period of despair✓ 正解病人在長期絕望後表達突然的平靜感
- CThe client talks about having 'no future' or feeling 'trapped'✓ 正解病人談論自己『沒有未來』或感到『被困住』
- DThe client starts to sleep for 12 hours a day病人開始每天睡12小時
- EThe client states, 'I have finally made a plan to end this pain'✓ 正解病人表示：『我終於制定了一個結束痛苦的計畫』
自殺風險評估（Suicide Risk Assessment）是精神科護理的最高優先級。當病人出現「突然平靜」的現象時，往往意味著自殺計畫已定，內心的掙扎已結束，這是一個極度危險的警訊。此外，交代後事（給予貴重物品）、表達無助感與絕望感，以及明確說明自殺計畫，均顯示病人已具備自殺的意圖與行動力，需立即採取安全防護措施（如一對一觀察）。
A sudden sense of peace, giving away prized possessions, expressing hopelessness, and stating a specific plan are all critical indicators of imminent suicide risk. These behaviors suggest the client has resolved their internal conflict and is prepared to act, necessitating immediate safety interventions such as one-to-one observation.
美國醫院對於自殺風險的評估採用標準化工具（如 Columbia-Suicide Severity Rating Scale），且對高風險病人有嚴格的 safety observation protocol（如 1:1 Sitter），護理師需精確記錄病人的 verbal and non-verbal cues。