護理師正在評估一位患有思覺失調症且有幻聽的病人。護理計畫應包含哪些措施？（選所有適合的）
A nurse is assessing a client who has been diagnosed with schizophrenia and is experiencing auditory hallucinations. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AAsk the client what the voices are saying✓ 正解詢問個案聲音在說什麼
- BAvoid discussing the voices with the client避免與個案討論聲音
- CMaintain a calm and structured environment✓ 正解維持平靜且有結構的環境
- DProvide reality-based activities to distract the client✓ 正解提供基於現實的活動以分散個案注意力
- EChallenge the reality of the voices to reduce symptoms挑戰聲音的現實性以減輕症狀
對於幻聽病人，必須評估幻聽內容以確認是否有指令性幻聽（如傷害自己或他人）。營造平靜環境可減低刺激誘發幻聽，透過現實導向活動則能協助病人轉移注意力。選項 B 錯誤，完全避談會錯失評估風險的機會。選項 E 錯誤，挑戰幻聽會使病人因恐懼而產生防衛心，甚至加重與護理師的衝突，無法有效緩解症狀。
For clients experiencing auditory hallucinations, the content of the hallucinations must be assessed to determine whether they are command hallucinations (such as commands to harm self or others). Creating a calm environment reduces stimuli that may provoke hallucinations, and reality-based activities help the client redirect attention. Option B is incorrect; completely avoiding the topic forfeits the opportunity to assess risk. Option E is incorrect; challenging the hallucinations causes the client to become defensive out of fear and may worsen conflict with the nurse, failing to effectively reduce symptoms.
在美國，這類評估被列入高風險照護標準；台灣對於思覺失調症的照護常強調藥物順從性，溝通技巧應用仍有進步空間。