— 心理社會完整性 · HARD · SATA —
護理師評估病人的自殺風險。下列哪些陳述顯示病人有立即介入的需求？（選所有適合的）
A nurse is assessing a patient for suicide risk. Which statements indicate an immediate need for intervention? (Select all that apply.)
- AI don't think I can go on like this anymore✓ 正解我不認為我能再這樣繼續下去了
- BI have been thinking about how I would end it✓ 正解我一直在想該如何結束生命
- CI have a plan and the means to carry it out✓ 正解我有計畫也有手段可以執行
- DI feel much better today because I have everything settled✓ 正解我今天感覺好多了，因為我一切都安排好了
- EI am worried about my medical bills我很擔心我的醫療費用
— Explanation · 中文詳解 —
評估自殺需特別警覺「計畫與可行性（C）」以及「情緒轉好（D）」，情緒突轉好常是病人已下定決心自殺的危險徵兆。E雖有壓力，但未達自殺立即風險。A, B, C, D 均需立即啟動 suicide precautions。
Statements indicating hopelessness, active planning, access to means, or sudden calmness after distress signal an immediate risk for suicide. These cues suggest the client may have decided to act on suicidal thoughts and requires urgent safety interventions. Immediate implementation of suicide precautions is necessary to ensure client safety.
✦ 台美臨床差異
台灣臨床依據標準自殺評估量表進行監控，護理師需於發現上述徵兆時立即通知醫師並執行防範措施。