— 心理社會完整性 · MEDIUM · MCQ —
一位思覺失調症個案出現聽幻覺，表示：「聲音告訴我我很壞。」護理師最具治療性的回應為何？
A client with schizophrenia is experiencing auditory hallucinations, stating, 'The voices are telling me I am bad.' Which nursing response is most therapeutic?
- AI understand that you hear these voices, but I do not hear them.✓ 正解我了解你聽到這些聲音，但我沒有聽到。
- BWhy do you think the voices are saying that about you?你為什麼認為聲音那樣說你？
- CI do not hear any voices, so you should ignore them.我沒有聽到任何聲音，所以你應該忽略它們。
- DLet's focus on something else so you don't have to listen to them.讓我們專注於別的事情，這樣你就不用聽它們了。
— Explanation · 中文詳解 —
護理原則為承認個案的真實感受（幻覺），但明確表示自己無法聽見該聲音，以維持現實檢驗。C 選項與 D 選項皆試圖駁斥或忽視幻覺，無助於建立信任；B 選項詢問『為什麼』容易使個案感到被質問，可能導致防衛心。
The nursing principle is to acknowledge the client's actual experience (the hallucination) while clearly stating that the nurse cannot hear the voices, thereby maintaining reality testing. Options C and D both attempt to refute or dismiss the hallucination and do not help build trust; option B, by asking "why," can make the client feel interrogated and may provoke defensiveness.
✦ 台美臨床差異
台美均遵循護理現實導向原則，但台灣對幻覺處理常結合抗精神病藥物衛教，護理師更傾向觀察個案是否遵從服藥。