護理師正在照護一位出現聽幻覺的病人。病人說：「聲音要我傷害自己。」護理師的首要行動是什麼？
A nurse is caring for a client experiencing auditory hallucinations. The client states, 'The voices are telling me to hurt myself.' What is the nurse's priority action?
- AAsk the client to ignore the voices.要求患者忽略這些聲音
- BStay with the client and initiate suicide precautions.✓ 正解陪伴患者並啟動自殺預防措施
- CAdminister an as-needed (PRN) antipsychotic medication.給予處方標示「必要時」(PRN) 的抗精神病藥物
- DEncourage the client to engage in distracting activities.鼓勵患者參與分散注意力的活動
當病人報告聽到指示其自我傷害的聲音時，這構成嚴重的安全威脅。護理師的首要行動是確保病人安全，這意味著必須留在病人身邊，並立即啟動自殺防治措施。雖然藥物（C）和轉移（D）可能是後續的一部分，但立即的陪伴和安全措施是絕對優先的。B 句不切實際。
When a client reports hearing voices commanding self-harm, this constitutes a serious safety threat. The nurse's first action is to ensure client safety, meaning the nurse must stay with the client and immediately initiate suicide precautions. Although medication (C) and distraction (D) may be part of later management, immediate presence and safety measures take absolute priority. Option A is unrealistic.
面對病人表示聽到指示自我傷害的聲音，美台護理師的反應都是確保病人安全。美國在自殺防治的標準化協議和記錄方面可能更為嚴謹。