一位個案正經歷家庭暴力。哪些護理措施是適當的？（選所有適合的）
A client is experiencing domestic violence. Which nursing actions are appropriate? (Select all that apply.)
- AAsk the client directly about the abuse✓ 正解直接向個案詢問是否遭受虐待
- BDocument the client's statements in their own words✓ 正解以個案自己的話記錄其陳述
- CInform the abuser of the conversation immediately立即告知施暴者有關對話內容
- DProvide information about local shelters and support✓ 正解提供當地庇護所和支援資訊
- EPhotograph injuries with the client's consent✓ 正解在徵得個案同意下拍攝傷勢照片
家庭暴力（Domestic Violence）屬於嚴重的心理社會健康問題，護理師的首要責任是提供安全、非批判性的護理環境。正確做法包括建立信任以利個案坦承、詳實記錄法律證據，以及提供社區資源。護理師必須確保個案隱私，絕不可在施暴者面前討論病情，以免引發後續暴力風險。拍攝傷勢需徵求病人同意，因為這屬於侵入性證據收集，法律上需尊重自主權。
When caring for a client experiencing domestic violence, nurses must prioritize safety and confidentiality by asking direct questions, documenting statements in the client's own words, and providing resources like shelter information. It is critical never to inform the abuser of the disclosure, and injury photography should only be performed with the client's explicit consent to preserve legal evidence.
在美國，護理師對於疑似家暴個案有強制通報義務（Mandatory Reporting），且若個案未成年或高齡，法規要求更為嚴格。台灣臨床雖亦重視隱私，但針對家暴的通報流程與法律責任（如責任通報）在美國 NCLEX 考題中更強調護理師在法律程序中的角色。