— 心理社會完整性 · MEDIUM · MCQ —
一位思覺失調症個案出現幻聽，下列哪項護理措施最具治療性？
A client with schizophrenia is experiencing auditory hallucinations. Which intervention is the most therapeutic for the nurse to implement?
- AAsk the client what the voices are saying to them✓ 正解詢問案主聲音在說什麼
- BChallenge the reality of the voices挑戰聲音的現實性
- CTell the client that the voices are not real告訴案主聲音不是真的
- DIgnore the hallucinations to discourage the behavior忽略幻聽以制止該行為
— Explanation · 中文詳解 —
護理人員應評估幻聽內容，尤其是指令性幻聽（Command hallucinations），因為這可能暗示暴力或自傷風險。同時，護理過程需維持同理心，避免直接質疑或否定病人的知覺，這會破壞護病關係並使個案更防衛。
The nurse should assess the content of the auditory hallucinations, especially command hallucinations, because these may signal a risk of violence or self-harm. At the same time, the nursing process must maintain empathy and avoid directly challenging or denying the client's perceptions, which would damage the nurse-client relationship and make the client more defensive.
✦ 台美臨床差異
美國強調安全評估與降低刺激；台灣臨床常配合抗精神病藥物調整與結構性活動安排。