— 心理社會完整性 · HARD · SATA —
護理師為憂鬱症病人進行自殺風險評估，應包含哪些問題來評估致死性？（選所有適合的）
A nurse is performing a suicide risk assessment for a client with depression. Which questions should the nurse include to assess for suicide lethality? (Select all that apply.)
- ADo you have a specific plan for how you would end your life?✓ 正解你是否有結束生命的具體計畫？
- BHow long have you been feeling depressed?你感到抑鬱多久了？
- CDo you have access to the means to carry out your plan?✓ 正解你是否擁有執行計畫的手段？
- DWhat are the reasons you have for wanting to live?✓ 正解你想要活下去的理由是什麼？
- EHave you made any attempts to end your life in the past?✓ 正解過去是否有過結束生命的嘗試？
— Explanation · 中文詳解 —
自殺評估的三大支柱為：意圖（Plan）、工具（Means/Access）與過去紀錄（History）。詢問計畫與工具可評估致死性與急迫性，詢問存活理由是為了建立保護因子，詢問過去病史能評估風險因子。B選項僅與診斷性質有關，對於評估當下的自殺「致死性」並無直接幫助。
Assessing suicide lethality requires evaluating the client's specific plan, access to lethal means, and history of past attempts, as these are strong predictors of risk. Identifying reasons for living helps establish protective factors essential for safety planning. The duration of depression does not directly indicate current lethality or immediate risk.
✦ 台美臨床差異
美國有極嚴格的自殺評估流程圖（如 Columbia Scale）；台灣臨床評估常視醫師評估為主，護理師較少使用結構化量表。