護理師照護一位有嚴重憂鬱且有自殺風險的病人時，下列哪些護理措施是適當的？（選所有適合的）
Which of the following nursing actions are appropriate when caring for a client who is exhibiting signs of severe depression and is at risk for suicide? (Select all that apply.)
- APlace the client in a room near the nurses' station✓ 正解將病人安置在護理站附近
- BRequest that the client sign a 'no-suicide contract'要求病人簽署『不自殺契約』
- CRemove all sharp objects and potentially harmful items from the room✓ 正解移除房間內所有銳利物品及潛在危險物品
- DAssign a staff member to provide one-to-one observation✓ 正解指派工作人員提供一對一監護
- ECheck the client's mouth after medication administration✓ 正解給藥後檢查病人口腔
自殺預防的首要任務是確保環境安全。監測病人是否藏藥（E）、移除危險物品（C）、近護理站監控（A）及一對一觀察（D）皆為必要的標準防護。簽訂「不自殺契約」（B）在實證醫學中已被證實無法有效預防自殺，不應作為主要的防護策略。
Ensuring environmental safety is the priority for clients at risk for suicide, which includes removing sharp objects and placing the client near the nurses' station for close monitoring. One-to-one observation is necessary for high-risk clients, and checking the mouth after medication administration prevents stockpiling for overdose. No-suicide contracts are not evidence-based and should not be relied upon as a primary safety strategy.
美國對自殺風險的評估使用標準化量表（如 C-SSRS），台灣臨床有時較依賴資深護理師的臨床直覺與經驗。