— 心理社會完整性 · HARD · SATA —
一位思覺失調症個案表示聽見命令其傷害他人的聲音，護理師應採取哪些護理措施？（選所有適合的）
A client with schizophrenia reports hearing voices that command them to hurt others. Which interventions are appropriate for this client? (Select all that apply.)
- AMaintain a safe, structured environment with 1:1 observation✓ 正解維持安全、結構化的環境並進行 1:1 觀察
- BAsk the client directly what the voices are saying to assess for command hallucinations✓ 正解直接詢問病人幻聽的內容，以評估是否有命令性幻覺
- CAgree with the client about the voices to build therapeutic rapport附和病人關於幻聽的說法，以建立治療性關係
- DEncourage the client to engage in activities that compete with the voices✓ 正解鼓勵病人參與能與幻聽競爭的活動
- EMinimize sensory stimulation to prevent worsening of symptoms✓ 正解減少感官刺激，以防止症狀惡化
— Explanation · 中文詳解 —
針對具攻擊性的命令幻聽，安全是最高指導原則。護理師需評估幻聽內容以判斷危險性，並隔離刺激來源。絕對不可附和病人的幻覺，應明確表示自己並未聽到該聲音，但尊重病人的感受。透過參與其他活動可轉移注意力，減低幻聽的干擾。
With aggressive command hallucinations, safety is the top priority. The nurse must assess hallucination content for danger and reduce stimulation. Never agree with the client's hallucinations; clearly state that you do not hear the voices while respecting the client's feelings. Engaging in alternative activities can distract and reduce hallucination interference.
✦ 台美臨床差異
美國採嚴格限制病人身體約束政策；台灣在急性精神病房中，身體約束的使用頻率相對較高。