一位患有精神分裂症的病人正經歷聽幻覺。護理師最合適的初步回應為何？
A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate initial response by the nurse?
- ASuggest the client listen to music to drown out the voices.建議病人聽音樂以掩蓋聲音。
- BTell the client that the voices are not real.告訴病人這些聲音不是真實的。
- CAsk the client, 'What are the voices telling you?'✓ 正解詢問病人：『這些聲音告訴你什麼？』
- DIgnore the client's statement about the voices.忽略病人關於聲音的陳述。
當精神分裂症（schizophrenia）病人經歷幻覺時，護理師的初步回應至關重要，應以病人安全為優先考量。幻覺，特別是聽幻覺，可能包含命令式幻覺（command hallucinations），指示病人傷害自己或他人。因此，護理師的首要任務是評估幻覺的內容，了解其是否具有威脅性。這不僅能確保病人和環境的安全，也能向病人傳達被傾聽和關心的訊息，建立治療關係。在評估後，護理師再根據幻覺的性質和病人的反應，提供進一步的支持性或現實導向的干預。
When a client with schizophrenia experiences hallucinations, the nurse's initial response is critical and must prioritize client safety. Hallucinations, particularly auditory ones, may include command hallucinations directing the client to harm themselves or others. Therefore, the nurse's first task is to assess the content of the hallucinations to determine whether they are threatening. This not only ensures the safety of the client and environment but also conveys to the client that they are being heard and cared for, building a therapeutic relationship. After assessment, the nurse can then provide further supportive or reality-oriented interventions based on the nature of the hallucinations and the client's response.
精神分裂症病人幻覺的護理干預原則在美國和台灣是高度一致的。兩地都強調護理師應以非批判性的態度傾聽，評估幻覺內容，尤其關注命令式幻覺帶來的安全風險，並在此基礎上提供支持性照護。這屬於精神科護理的核心能力，無顯著差異。