— 心理社會完整性 · HARD · SATA —
一位思覺失調症病人表現出社交隔離及聽幻覺，護理計畫中應包含哪些措施？（選所有適合的）
A client is diagnosed with schizophrenia and is exhibiting signs of social isolation and auditory hallucinations. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AAsk the client what the voices are saying詢問病人聲音在說什麼
- BEncourage the client to attend group activities✓ 正解鼓勵病人參加團體活動
- CUse a calm, matter-of-fact tone when speaking✓ 正解說話時使用平靜、公事公办的語氣
- DValidate the reality of the voices to reduce anxiety確認聲音的真實性以降低焦慮
- EProvide brief, structured interactions✓ 正解提供簡短、結構化的互動
— Explanation · 中文詳解 —
針對思覺失調症，護理應以現實導向為主。C、E 能提供安全感並減少過度刺激。B 可幫助病人重建人際連結。A 需謹慎處理，僅在評估自傷風險時詢問，而非鼓勵聚焦幻覺。D 是錯誤的，不可附和虛假的現實，會強化病人的精神症狀。
For schizophrenia, care should be reality-oriented. C and E provide safety and limit overstimulation. B helps rebuild social connection. A should be used cautiously — only when assessing self-harm risk, not to encourage focus on hallucinations. D is wrong — validating the hallucinations reinforces psychotic symptoms.
✦ 台美臨床差異
台美皆強調現實導向，但台灣對於參與團體活動的執行強度視醫院資源而定。