— 心理社會完整性 · MEDIUM · MCQ —
護理師與一位客戶晤談，客戶表示：「我聽到聲音說有人在監視我。」護理師最治療性的回應為何？
A nurse is interviewing a client who states, 'I hear voices saying that people are watching me.' Which response by the nurse is most therapeutic?
- AYou should not listen to those voices.你不應該聽那些聲音。
- BI do not hear any voices, but I understand they are real to you.✓ 正解我沒有聽到任何聲音，但我理解這對你來說很真實。
- CWhy do you think people are watching you?你為什麼認為有人正在監視你？
- DTell me more about what the voices are saying.告訴我更多關於那些聲音在說什麼。
— Explanation · 中文詳解 —
面對思覺失調症（Schizophrenia）出現幻聽的病人，護理師應採取「現實測試（Reality Testing）」的回應方式。這意味著護理師不認同病人的幻聽內容，但承認這些聲音對病人而言是真實的。這種回應既能維持治療性關係，又能避免病人將護理師納入其妄想系統，同時展現同理心，鼓勵病人將焦點轉向現實世界。
When responding to a client with schizophrenia who experiences auditory hallucinations, the nurse should use reality testing. This means that the nurse does not validate the content of the voices but acknowledges that the voices are real to the client. This response maintains a therapeutic relationship, avoids being drawn into the client's delusional system, and demonstrates empathy while encouraging the client to refocus on reality.