一位思覺失調症病人表示聽到有人指令他傷害自己。護理師應優先採取何種行動？
A client with schizophrenia reports hearing voices telling them to harm themselves. Which action should the nurse prioritize?
- ARedirect the client to a group activity將病人轉移至團體活動
- BAdminister an antipsychotic medication給予抗精神病藥物
- CAsk the client what the voices are saying詢問病人幻聽的內容
- DEnsure the client's immediate safety through observation✓ 正解透過觀察確保病人的即時安全
面對有自殺意念或傷害指令幻聽（command hallucinations）的病人，護理師的首要任務是確保病人的物理安全。持續觀察（one-on-one observation）是預防病人執行傷害行為的最直接方法。在確保安全後，才能進行評估與治療介入。直接詢問幻聽內容雖有助於評估風險，但若病人正處於危急狀態，維持觀察為優先。
When caring for a client with suicidal ideation or command hallucinations to self-harm, the nurse's first priority is to ensure the client's physical safety. Continuous one-on-one observation is the most direct method for preventing the client from acting on the harmful command. Once safety is secured, further assessment and therapeutic interventions can take place. Although asking about hallucination content is useful for risk assessment, monitoring takes priority when the client is in acute crisis.