一位患有重度憂鬱症病史的病人因自殺意念入院。在初步評估中，病人表示：「我終於有了一個行得通的計畫，我現在感到平靜多了。」護理師應優先採取哪項行動？
A client with a history of Major Depressive Disorder is admitted for suicidal ideation. During the initial assessment, the client states, 'I finally have a plan that will work, and I feel much more at peace now.' Which action by the nurse is the priority?
- AAsk the client to describe the specific plan✓ 正解請個案描述具體計畫
- BAdminister the prescribed antidepressant medication給予處方之抗憂鬱藥物
- CAllow the client to have some quiet time alone允許個案安靜獨處
- DDocument the client's statement in the medical record將個案之陳述記錄於病歷中
此題的核心概念是自殺風險評估。當病人表達「感到平靜」或「已有計畫」時，通常暗示其已下定決心執行自殺，風險反而比處於深度憂鬱、無力行動時更高。護理師必須立即評估計畫的具體性、可行性與致命性。核心思路是「直接詢問法」，這不會增加病人自殺的念頭，反而能獲取關鍵的安全資訊。在護理優先原則中，安全（Safety）永遠高於文書作業或常規給藥。獲取具體計畫後，才能決定後續的監測層級（如 1:1 持續監視）。
When a client expresses feeling at peace after developing a suicide plan, it signals a high risk of imminent action rather than improvement. The priority nursing action is to directly assess the lethality and specificity of the plan to determine the level of danger. This direct inquiry is essential for safety planning and does not increase the risk of suicide, unlike providing alone time or delaying assessment for documentation.
在美國 NCLEX 考試中，強調「直接詢問」自殺計畫是評估標準；在台灣臨床實務中，部分資淺護理師可能擔心詢問會刺激病人，但現代精神護理教育已與國際接軌，強調必須具體評估計畫細節以落實安全防護。