一位思覺失調症個案出現活動性幻覺徵象。下列哪些護理措施是適當的？（選所有適合的）
A client with schizophrenia is exhibiting signs of active hallucinations. Which of the following nursing interventions are appropriate? (Select all that apply.)
- AAsk the client what the voices are saying✓ 正解詢問病人聲音在說什麼
- BValidate the reality of the hallucinations to reduce anxiety驗證幻覺的真實性以降低焦慮
- CRedirect the client to reality-based activities✓ 正解引導病人參與基於現實的活動
- DMaintain a low-stimulation environment✓ 正解維持低刺激的環境
- EAvoid using touch without informing the client first✓ 正解在未告知病人的情況下避免使用觸碰
護理幻覺病人時，應詢問其幻覺內容以評估暴力傾向（A）。需將焦點轉移至現實（C），創造低刺激環境以防幻覺惡化（D）。由於病人可能有妄想或被攻擊感，觸碰前需先告知以示尊重並維持信任（E）。絕對不可認同幻覺（B），應協助病人連結現實。
When caring for a client with hallucinations, asking about the content helps assess for command hallucinations and violence risk (A). The nurse redirects the client to reality-based activities (C) and creates a low-stimulation environment to prevent worsening (D). Because the client may have delusions or feel threatened, touch should be announced beforehand to maintain respect and trust (E). The nurse must never validate the hallucination (B); the goal is to anchor the client to reality.
台美醫療團隊皆強調不認同幻覺，台灣臨床在執行此類衛教時，常會結合病房管理規範與安全約束指引。