— 心理社會完整性 · HARD · MCQ —
一位思覺失調症個案報告聽到命令其傷害他人的聲音。護理師的優先處置為何？
A client with schizophrenia reports hearing voices that command them to harm others. What is the nurse's priority action?
- AEnsure the safety of the client and others✓ 正解確保病人及他人的安全
- BRedirect the client to a group activity將病人轉移至團體活動
- CAdminister prescribed antipsychotic medication給予處方的抗精神病藥物
- DAsk the client what the voices are saying詢問病人聲音在說什麼
— Explanation · 中文詳解 —
出現命令型幻聽（Command Hallucinations）且內容涉及傷害他人時，個案具有立即的危險性。護理師首要任務是採取適當的安全防護措施，保護個案本人及周遭人員，包括減少活動刺激、評估危險程度或依規定啟動緊急通報程序。
When command hallucinations occur and the content involves harming others, the client presents an immediate danger. The nurse's first priority is to implement appropriate safety measures to protect the client and surrounding individuals, including reducing environmental stimulation, assessing the level of dangerousness, and activating emergency notification procedures per policy.
✦ 台美臨床差異
美台精神醫療皆嚴格執行評估，但台灣對於具暴力傾向個案的身體約束使用規範較為嚴謹。