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在門診個案說「我今晚有計畫要自殺。」之後，將護理措施依序排列。

Ordered Response

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Ask directly about the current thoughts, plan, timing, access to means, prior attempts, and immediate protective factors 直接詢問目前的想法、計畫、時間、取得方法的途徑、先前的嘗試，以及立即的保護因子

Notify the responsible clinician or emergency team that the client has current intent and cannot be left alone 通知負責的臨床醫師或緊急團隊，說明個案目前有自殺意圖且不能獨處

Remain with the client, move to a safer observable area, remove accessible hazards, and summon trained help 留在個案身邊，將個案移至較安全且可觀察的區域，移除可及的危險物品，並呼叫受過訓練的協助人員

Document the client's words, assessment findings, safety measures, notifications, and disposition 記錄個案的話語、評估結果、安全措施、通知事項及後續處置

Arrange the urgent mental-health evaluation and secure transfer; involve supports only with consent or as emergency policy permits 安排緊急精神衛生評估及安全轉送；僅在個案同意或緊急政策允許時才納入支持系統

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相同主題的下一題A nurse is admitting a 32-year-old client to an inpatient mental health unit with a diagno…本題收錄於此題庫[전통+신유형] NCLEX LEVEL UP 패키지KRW 79,000

僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。