— 心理社會完整性 · HARD · MCQ —
一名青少年因自傷行為住院。入院時的優先處置為何？
A nurse is caring for an adolescent client who has been hospitalized for self-harm. Which action is the priority upon admission?
- AImplement a suicide precaution protocol✓ 正解實施自殺防範協議
- BInterview the client about family stressors訪談個案關於家庭壓力源
- CEstablish a therapeutic relationship建立治療性關係
- DIdentify the primary trigger for the self-harm識別自傷的主要觸發因子
— Explanation · 中文詳解 —
對於有自傷史的個案，安全永遠是護理優先級的第一位。在未建立安全環境前，探索壓力源或建立治療關係均屬於次要。執行自殺防範方案（如移除危險物品、加強監測）能即時防止二次傷害，是進行任何心理治療介入的基礎。
Immediate safety is the priority for a client with a history of self-harm, making the implementation of suicide precautions essential upon admission. Interventions such as removing dangerous items and increasing monitoring prevent further injury before addressing psychosocial needs. Building a therapeutic relationship and identifying triggers are important but occur only after physical safety is ensured.
✦ 台美臨床差異
台美在自殺防範流程上皆有嚴格標準，但美國在青少年個案隱私法規（如 HIPAA 與州法）上更為複雜。