— 心理社會完整性 · HARD · SATA —
護理師進行自殺風險評估。下列哪些發現代表個案處於最高即時風險？（選所有適合的）
A nurse is performing a suicide risk assessment. Which findings indicate the highest immediate risk for the client? (Select all that apply.)
- APresence of a detailed suicide plan✓ 正解有詳細的自殺計畫
- BHistory of previous suicide attempts✓ 正解有既往自殺嘗試史
- CStating that they have access to a lethal weapon✓ 正解表示擁有致命武器
- DExpressing that they feel lonely and sad表達感到孤單和悲傷
- EHaving a sudden, unexplained improvement in mood✓ 正解情緒突然不明原因地改善
— Explanation · 中文詳解 —
自殺風險評估的核心在於識別「立即性威脅」。評估指標包括：是否有具體計畫（Plan）、取得致命工具的管道（Means）、過去自殺未遂史（History），以及情緒突然改善（暗示個案可能已下定決心自殺，心理負擔減輕）。護理師必須將這些因素視為高危險警訊，並採取嚴格的自殺防護措施（Suicide Precautions）。
Highest immediate suicide risk is indicated by the presence of a detailed plan, access to lethal means, a history of previous attempts, and a sudden unexplained improvement in mood. These factors suggest strong intent and capability to act, whereas feelings of loneliness or sadness alone are less specific predictors of imminent danger. Nurses must implement strict suicide precautions when these high-risk indicators are present.