— 心理社會完整性 · HARD · SATA —
評估病人是否有自我傷害意圖時，護理師應監測哪些行為？（選所有適合的）
Which behaviors should the nurse monitor for when assessing a client for potential self-directed violence? (Select all that apply.)
- AGiving away prized possessions✓ 正解贈送心愛之物
- BSudden increase in energy and mood✓ 正解能量與情緒突然增加
- CVerbally expressing feelings of hopelessness✓ 正解口頭表達絕望感
- DWithdrawing from social activities✓ 正解退出社交活動
- EIncreased appetite and weight gain食慾增加與體重增加
— Explanation · 中文詳解 —
自殺風險評估重點在於徵兆：處理身後事（送貴重物品）、突如其來的能量回升（可能已決定執行計畫）、表達絕望感、社會退縮。E 選項通常與憂鬱症導致的食慾下降相反，非典型抑鬱雖可能增加，但相較前四者非核心指標。
The nurse should monitor for behaviors indicating finalized plans for suicide, such as giving away prized possessions, sudden improvements in mood or energy, verbal expressions of hopelessness, and social withdrawal. These signs suggest the client may be preparing for death or has resolved to act on suicidal ideation. Increased appetite is not typically associated with acute suicidal risk.
✦ 台美臨床差異
美國護理環境強調自殺風險篩檢工具（如 C-SSRS）；台灣雖有篩檢量表，但在繁忙臨床中常依賴護理師的觀察與警覺度。