一位思覺失調症病人出現幻聽，對護理師表示：「那些聲音叫我從窗戶跳下去。」護理師應立即採取什麼行動？
A client with schizophrenia is exhibiting signs of active hallucinations. The client tells the nurse, 'The voices are telling me to jump out the window.' Which action should the nurse take next?
- AAsk the client to describe what the voices are saying in more detail.請個案更詳細描述聲音的內容
- BRedirect the client to a group therapy session to distract them.引導個案參加團體治療以轉移注意力
- CEnsure the client is in a safe environment and implement 1:1 observation.✓ 正解確保個案處於安全環境並實施一对一監護
- DAdminister the prescribed PRN antipsychotic medication immediately.立即給予處方之備用抗精神病藥物
當思覺失調症病人出現命令式幻聽（Command hallucinations），且內容涉及自傷或傷人時，這屬於精神科急症。護理師的首要任務是確保病人與周遭環境的安全。執行一對一監控（1:1 Observation）能防止病人採取自殺行為，這是護理師在第一時間必須執行的安全措施，隨後才進行藥物評估或進一步的心理評估。
When a client with schizophrenia experiences command hallucinations involving self-harm or harm to others, this is a psychiatric emergency. The nurse's first priority is to ensure the safety of the client and the surrounding environment. Implementing 1:1 observation can prevent the client from carrying out suicidal behavior; this is the immediate safety measure the nurse must perform first, followed by medication evaluation or further psychological assessment.