— 心理社會完整性 · HARD · MCQ —
護理師與一位表達自我價值感低落且有自傷意念的青少年進行晤談。哪項措施是最高優先級？
A nurse is interviewing an adolescent who expresses feelings of worthlessness and thoughts of self-harm. Which action is the highest priority?
- AContract with the client to promise they will not self-harm與個案簽訂不再自傷的契約
- BNotify the parents immediately to discuss the situation立即通知父母以討論此情況
- CAssign the client to a private room for total isolation將個案安排至私人病房進行完全隔離
- DAsk the client about the specific plan and means for self-harm✓ 正解詢問個案關於自傷的具體計畫與手段
— Explanation · 中文詳解 —
針對有自殺意念的病人，評估自殺計畫的具體性與致命性是護理師的首要任務。只有了解計畫的詳細程度（如工具、地點、時間），才能決定保護性隔離或防範措施的強度。A 選項已被證實無效；B 選項雖重要，但評估風險優先；C 選項會使病人更孤立，增加危險。
The highest priority when assessing a client with self-harm ideation is to determine the specific suicide risk by asking about their plan, means, and intent. While parental notification and safety measures are important, they follow a thorough risk assessment. No-harm contracts are ineffective, and isolation can increase distress, making direct assessment of the plan the critical first step.
✦ 台美臨床差異
美國有明確的病人安全標準作業程序；台灣對於未成年人心理健康的隱私權保護與家屬知情權平衡更為謹慎。