— 心理社會完整性 · HARD · MCQ —
護理師正在評估一位出現聽幻覺的思覺失調症病人，下列哪項反應最具治療性？
A nurse is assessing a client with schizophrenia who is experiencing auditory hallucinations. Which response by the nurse is most therapeutic?
- AChange the subject to reality-based topics將話題轉移至基於現實的主題
- BAsk the client to ignore the voices要求病患忽略聲音
- CAsk the client what the voices are saying✓ 正解詢問病患聲音在說什麼
- DTell the client that the voices are not real告訴病患聲音並非真實存在
— Explanation · 中文詳解 —
當病人出現幻覺時，護理師應評估其內容，特別是是否存在指令性幻覺（Command hallucinations），以評估對他人或自己的潛在危險性。否定幻覺（D）或要病人忽視（B）均無效，因為對病人而言，幻覺的體驗是真實且強烈的。
When a client experiences hallucinations, the nurse should assess their content—particularly to determine whether command hallucinations are present—in order to evaluate potential danger to self or others. Denying the hallucinations (D) or telling the client to ignore them (B) is ineffective because the experience is real and intense for the client.
✦ 台美臨床差異
台灣部分文化背景對精神疾患仍有汙名化，護理師在確認幻覺時需特別注意隱私與降低病人的羞恥感。