— 心理社會完整性 · HARD · MCQ —
當病人表達自殺意念時，護理師應採取什麼行動？
Which action should the nurse take when a client expresses suicidal ideation?
- AImmediately place the client on one-to-one observation立即安排病人接受一對一監護
- BAvoid mentioning the suicide to prevent giving the client ideas避免提及自殺以避免給病人念頭
- CAssure the client that everything will be okay向病人保證一切都會好轉
- DAsk the client if they have a specific plan and means✓ 正解詢問病人是否有具體的計畫和手段
— Explanation · 中文詳解 —
評估自殺意念的嚴重性是第一步。詢問具體計畫與工具可評估自殺風險程度（ lethality），這對醫療團隊評估入院必要性至關重要。A 需根據風險評估等級執行，若未了解危險性直接上觀察可能過度限制；C 為虛假安慰；B 是錯誤觀念，直接討論反而能降低自殺衝動。
Assessing the severity of suicidal ideation is the first step in ensuring client safety. Asking about a specific plan and means allows the nurse to evaluate lethality, which is critical for determining the need for admission and safety planning. While observation may be necessary, it must be based on this initial risk assessment rather than applied indiscriminately.
✦ 台美臨床差異
美國護理師有嚴格的自殺風險評估表（如 C-SSRS）；台灣臨床多由精神科醫師進行正式評估，護理師進行觀察。