一名思覺失調症患者表示：「幻聽說 FBI 正在跟蹤我。」護理師採取何種行動最適當？
A client with schizophrenia states, 'The voices are telling me that I am being followed by the FBI.' Which action is the most appropriate for the nurse to take?
- AAsk the client what the voices are telling them to do✓ 正解詢問病人幻聽指示他們做什麼
- BAgree with the client to establish rapport附和病人的說法以建立良好關係
- CExplain that the hospital is a safe environment解釋醫院是一個安全的環境
- DTell the client that the voices are not real告訴病人幻聽並不真實
思覺失調症患者出現幻聽時，護理師應評估是否帶有命令式內容（Command hallucinations），這對病人及其周遭有潛在暴力或自殺危險。D 選項與病人爭辯事實會破壞關係，B 選項贊同妄想是不誠實的治療行為，C 選項雖正確但未能評估安全性危機。
When a patient with schizophrenia experiences auditory hallucinations, the nurse should assess whether they have command content (command hallucinations), which pose a potential risk of violence or suicide to the patient and those around them. Option D, arguing with the patient about the facts, damages the relationship; option B, agreeing with the delusion, is a dishonest therapeutic action; and although option C is correct, it fails to assess the safety crisis.
台美在精神護理評估原則一致，均以安全性評估為首要，但在台灣病患常規會伴隨抗精神病藥物治療。