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一位因重度憂鬱症住院的個案說：「如果我不再醒來，對大家都好。」請為每項護理回應選出最佳分類。

Matrix

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	Therapeutic assessment or communication治療性評估或溝通	Immediate safety action立即安全行動	Unsafe or delays care不安全或延誤照護
Ask clearly whether the client is thinking of killing themself and assess plan, method, and access清楚詢問個案是否正在考慮自殺，並評估計畫、方法與取得途徑
Thank the client for speaking up and listen calmly without judgment感謝個案說出來，並以不帶批判的態度平靜傾聽
If suicidal thoughts are current, keep the client in sight, remove dangerous objects, alert the clinician, and obtain urgent evaluation若目前有自殺意念，讓個案保持在視線範圍內、移除危險物品、通知臨床醫師，並安排緊急評估
If the screen is positive but thoughts are not current, promptly complete a brief suicide safety assessment and notify the clinician若篩檢陽性但目前已無自殺意念，立即完成簡短的自殺安全評估並通知臨床醫師
Promise secrecy or rely on a no-suicide contract instead of assessing risk承諾保密或依賴不自殺契約，而不評估風險
Leave the client alone, document the statement, and assess during the next routine round讓個案獨處、記錄該陳述，並在下一次常規巡房時再評估

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