— 心理社會完整性 · MEDIUM · MCQ —
護理師訪談時，個案表示：「過去兩週一直聽到有聲音叫我去傷害自己。」護理師接下來應採取什麼行動？
A nurse is interviewing a client who states, 'I have been hearing voices telling me to hurt myself for the past two weeks.' Which action should the nurse take next?
- AImmediately initiate suicide precautions and safety observation✓ 正解立即啟動防自殺 precautions 及安全觀察
- BAdminister an antipsychotic medication as ordered依醫囑給予抗精神病藥物
- CAsk the client to describe what the voices sound like請病人描述聲音聽起來如何
- DDocument the hallucinations in the medical record在病歷中記錄幻聽
— Explanation · 中文詳解 —
個案出現命令式幻聽，且內容涉及自我傷害，這代表病人正處於高度危險狀態。護理師的第一原則是維護病人的安全，必須立即啟動自殺防範措施，例如密切觀察、移除危險物品並限制活動，確保個案不會執行幻聽內容，後續再進行評估與藥物治療。
The patient is experiencing command auditory hallucinations involving self-harm, indicating an extremely high-risk state. The nurse's first priority is to ensure patient safety by immediately initiating suicide-precaution measures — including close observation, removal of dangerous objects, and activity restriction — to prevent the patient from acting on the voices. Further assessment and pharmacologic treatment can follow.
✦ 台美臨床差異
台美兩地在自殺防治流程高度一致，皆要求遇有命令式幻聽時，必須立刻執行保護性隔離或一對一照護。