病人說：「我聽到有人在輕聲叫我的名字，但我知道那邊沒人。」護理師應如何記錄？
A client states, "I hear someone whispering my name, but I know nobody is there." How should the nurse document this?
- AClient is experiencing delusional thinking病人正經歷妄想思維
- BClient is experiencing auditory hallucinations with preserved reality testing✓ 正解病人正經歷聽覺幻覺，且現實檢驗能力保留
- CClient is experiencing auditory hallucinations病人正經歷聽覺幻覺
- DClient is experiencing illusions病人正經歷錯覺
護理記錄必須精確描述病人的精神狀態。病人描述的現象屬於「幻聽（Auditory hallucinations）」，因為其感知到外部並無來源的聲音。但關鍵在於病人能判斷「那邊沒人」，這顯示病人的現實感（Reality testing）依然完好。在精神科護理記錄中，區分「幻覺伴隨現實感喪失」與「幻覺伴隨現實感維持」對於診斷與照護計畫至關重要。
Nursing documentation must accurately reflect the client's mental state. The phenomenon described is an auditory hallucination, because the client perceives a sound that has no external source. The key feature, however, is that the client recognizes that 'nobody is there,' indicating that reality testing remains intact. In psychiatric nursing documentation, distinguishing between hallucinations with loss of reality testing and hallucinations with preserved reality testing is critical for diagnosis and care planning.