一位思覺失調症病人表示聽到聲音告訴他停藥。護理師的首要行動為何？
A client with schizophrenia reports hearing voices telling him to stop taking his medications. What is the nurse's priority action?
- AAdminister the medication as prescribed immediately立即依醫囑給藥
- BTell the client that the voices are not real告知病人這些聲音並非真實
- CAsk the client what the voices are saying詢問病人聲音說了什麼
- DAssess the content of the voices for command hallucinations✓ 正解評估聲音內容是否為命令性幻覺
聽幻覺（Auditory hallucinations）是思覺失調症的常見症狀。護理師評估的優先級在於判斷幻覺是否包含「指令性內容」（Command hallucinations），例如「去傷害自己」或「去傷害他人」。這是直接威脅病人與他人生命安全的關鍵資訊。確認幻覺內容後，護理師才能採取相對應的監控層級與防護措施。否定幻覺（B）或詢問細節（C）均不是首要的安全評估目標。
Auditory hallucinations are a common symptom of schizophrenia. The nurse's assessment priority is to determine whether the hallucinations contain command content, such as "hurt yourself" or "hurt others." This is the key information that directly affects the safety of the patient and others. Only after the content of the hallucination has been clarified can the nurse implement an appropriate level of monitoring and protective measures. Denying the hallucination (B) or asking for detailed descriptions (C) are not the priority safety assessment.