— 心理社會完整性 · HARD · MCQ —
一位思覺失調症病人告訴護理師：「聲音在叫我傷害自己。」下列何者為優先護理措施？
A client with schizophrenia tells the nurse, 'The voices are telling me to hurt myself.' Which action is the priority?
- AAsk the client what the voices are saying詢問病人聲音說了什麼
- BRedirect the client to a group activity to distract them引導病人參與團體活動以分散注意力
- CMaintain safety and initiate suicide precautions✓ 正解維持安全並啟動自殺預防措施
- DAdminister an antipsychotic medication給予抗精神病藥物
— Explanation · 中文詳解 —
面對命令式幻聽（Command Hallucinations），個案的安全是護理照護的最優先事項。評估後應立即採取自殺防範措施（Suicide Precautions），包括密切觀察及移除危險物品。了解幻聽內容雖然重要，但必須在確保病人安全之後進行。
For command hallucinations, client safety is the highest priority of nursing care. After assessment, suicide precautions should be initiated immediately, including close observation and removal of dangerous objects. Although understanding the content of the hallucinations is important, it must be done after ensuring the client's safety.
✦ 台美臨床差異
美國有明確的自殺防範分級制度（Safety Watch）；台灣病房通常採一對一護理照護。