— 心理社會完整性 · HARD · SATA —
護理師正在照護一位有憂鬱症史和被動自殺意念的病人。下列何者需要立即追蹤？（選所有適合的）
A nurse is caring for a client with a history of depression and passive suicidal ideation. Which of the following requires immediate follow-up? (Select all that apply.)
- AClient states, 'I wish I wouldn't wake up tomorrow.'✓ 正解病人表示：『我希望明天醒不過來。』
- BClient states, 'I have been researching lethal doses of medications.'✓ 正解病人表示：『我一直在研究藥物的致命劑量。』
- CClient states, 'My family would be better off without me.'✓ 正解病人表示：『沒有我，我的家人會過得更好。』
- DClient states, 'I haven't been eating much lately.'病人表示：『我最近吃得不多。』
- EClient states, 'I feel so tired all the time.'病人表示：『我一直覺得很疲倦。』
— Explanation · 中文詳解 —
A, B, C 都表示了更為具體的自殺意念或計畫，需要立即的評估和介入。A 句表達了不願活著的願望；B 句顯示了具體的計畫和手段；C 句表達了成為負擔的想法，可能與自殺意圖相關。D 和 E 句是憂鬱症的常見症狀，但不如 A, B, C 直接指示自殺風險。
Statements expressing a wish not to wake up, researching lethal means, or feeling like a burden indicate active suicidal ideation and intent, requiring immediate intervention. These cues suggest a higher risk of self-harm compared to general depressive symptoms like fatigue or poor appetite. The nurse must assess for specific plans and ensure the client's safety promptly.
✦ 台美臨床差異
美台護理師在評估自殺風險時，都會關注病人是否有計畫和意圖。在台灣，家庭支持網絡的介入可能更為常見，美國則可能更強調病人自主和個人安全計畫。