— 心理社會完整性 · MEDIUM · MCQ —
一位急診病人表達有自殺意念。護理師最優先的處置為何？
A client in the emergency department expresses suicidal ideation. Which of the following is the highest priority for the nurse?
- AInitiate a suicide risk assessment開始進行自殺風險評估
- BIdentify the client's support system確認客戶的支持系統
- CPlace the client on a one-to-one observation✓ 正解安排病人接受一對一監護
- DAdminister an antianxiety medication給予處方的抗焦慮藥物
— Explanation · 中文詳解 —
安全性是護理的首要任務。當病人明確表達自殺意念時，預防其採取行動的物理性防護即刻優於評估或訪談。一對一觀察（One-to-one observation）是防止自傷或自殺的黃金標準，確保病人處於護理師視線範圍內，隨時介入潛在危險行為。
Safety is the nurse's highest priority for a client expressing suicidal ideation. Placing the client on one-to-one observation ensures constant supervision and immediate intervention if self-harm attempts occur, making it the most critical action over assessment or medication administration.
✦ 台美臨床差異
台美皆採一對一監控，但美國法律對於強制留置（Involuntary commitment）的流程有更嚴格的行政審查。