— 心理社會完整性 · HARD · MCQ —
一位思覺失調症病人表示聽到聲音指示要傷害他人。護理師的首要行動為何？
A client with schizophrenia reports hearing voices telling them to harm others. What is the nurse's priority action?
- ADocument the hallucinations in the medical record在病歷中記錄幻聽
- BEnsure the safety of the client and others through direct observation✓ 正解透過直接觀察確保病人及他人的安全
- CAsk the client to describe what the voices are saying請病人描述聲音的內容
- DAdminister an antipsychotic medication施用抗精神病藥物
— Explanation · 中文詳解 —
安全是護理的第一優先。當病人出現命令式幻聽且內容涉及攻擊他人時，護理師必須立刻採取防範措施以避免暴力發生。此時評估幻聽內容固然重要，但確保環境安全與監測行為動向為保護性處置的當務之急，預防傷害事件發生。
Safety is the priority in nursing. When a client experiences command auditory hallucinations to harm others, the nurse must immediately implement preventive measures to avoid violence. Assessing hallucination content matters, but ensuring environmental safety and monitoring behavior take precedence to prevent harm.
✦ 台美臨床差異
台美皆重視自殺/暴力評估。美國護理師對「危險行為」的法律責任義務（Duty to Warn）界定更嚴格。