— 心理社會完整性 · HARD · SATA —
一位病人因自殺未遂入院，護理師應採取哪些措施以確保其安全？（選所有適合的）
A client is admitted following a suicide attempt. Which interventions should the nurse prioritize to ensure safety? (Select all that apply.)
- AAssign the client to a room near the nursing station✓ 正解將病人安置於靠近護理站的房間
- BRemove all sharp objects and cords from the room✓ 正解移除房間內所有銳器與繩索
- CInitiate one-to-one observation✓ 正解實施一對一觀察
- DExplain that suicide is a selfish act說明自殺是自私的行為
- ECheck the client's mouth after medication administration✓ 正解給藥後檢查病人的口腔
— Explanation · 中文詳解 —
自殺預防首重環境安全。近護理站便於觀察（A）、移除危險物品（B）與持續的一對一監測（C）是基本策略。給藥後檢查口腔（E）可預防病人囤積藥物。選項 D 是價值批判，嚴重違反護理倫理，會引發病人的罪惡感與憤怒。
Ensuring the safety of a client who has attempted suicide involves implementing strict environmental controls and continuous monitoring. Placing the client near the nursing station, removing potential ligature points or sharp objects, and initiating one-to-one observation are critical preventive strategies. Checking the mouth after medication administration ensures the dose was taken and prevents hoarding.
✦ 台美臨床差異
美國有嚴格的 Suicide Precautions 流程標準；台灣各醫院針對自殺個案有評估工具（如 CSSRS），執行標準大同小異。