一位思覺失調症個案出現聽幻覺並大喊：「聲音叫我從窗戶跳下去！」護理師應優先採取什麼行動？
A client with schizophrenia is experiencing auditory hallucinations and shouts, 'The voices are telling me to jump out the window!' Which action should the nurse take first?
- ATell the client that the voices are not real.告訴個案聲音是不真實的
- BEnsure the client's safety by staying with them and moving away from the window.✓ 正解透過陪伴個案並將其帶離窗邊來確保個案安全
- CAsk the client what the voices are saying.詢問個案聲音說了什麼
- DAdminister an as-needed dose of antipsychotic medication.給予適量之抗精神病藥物
面對思覺失調症（Schizophrenia）個案出現「指令型幻覺（Command Hallucinations）」，且內容涉及傷害自己（跳窗），護理師應視為高度自殺風險。首要優先行動（Priority Action）永遠是確保病人安全，將病人移離危險環境並提供持續陪伴，能有效中斷幻覺的執行力。藥物給予與深入探討幻覺內容皆為次要步驟。
When a client with schizophrenia experiences command hallucinations, especially with content involving self-harm (such as jumping out of a window), the nurse should regard the situation as high suicide risk. The first priority action is always to ensure the patient's safety; moving the patient away from the dangerous environment and providing continuous companionship can effectively interrupt the patient's ability to act on the hallucinations. Administering medication and exploring the content of the hallucinations in depth are secondary steps.