# 一位個案說：「我計劃今晚自殺。」護理師的優先行動是什麼？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396619&lang=zh-tw  
> language: zh-TW  
> subject: Mental Health Concepts  
> category: PSI

## 題目

一位個案說：「我計劃今晚自殺。」護理師的優先行動是什麼？

## 選項

1. 留在個案身邊並啟動自殺安全防範措施。 **✔ 正確答案**
2. 承諾保守秘密以建立信任。
3. 讓個案獨處以整理個人物品。
4. 告訴個案要正面思考，明天再重新評估。

**正確答案: 1**

## 解析

具體的自殺計劃需要立即採取安全防範措施，包括留在個案身邊並根據政策減少接觸自殺工具的機會。承諾保密、讓個案獨處或延遲行動都是不安全的。應在維持安全的同時進行治療性溝通。

## 深入解析

臨床判斷
利用個案線索、時機、檢驗數據和安全風險，選擇最符合自殺安全防範措施的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非單獨的記憶。

## 臨床情境

臨床實務指引
對於自殺安全防範措施，將完整的線索模式與個案當前的穩定性、醫囑數據和預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **自殺風險** — 一個人可能試圖自我傷害並意圖死亡的風險。
- **安全防範措施** — 用於降低立即傷害風險的環境和觀察措施。
- **治療性陪伴** — 在個案痛苦時，以冷靜支持的態度陪伴在側。

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