— 心理社會完整性 · HARD · MCQ —
護理師照護一位思覺失調症病人，病人表示：「腦中的聲音叫我去跳樓。」請問哪項行動優先？
A nurse is caring for a client with schizophrenia who claims, 'The voices are telling me to jump.' Which action is the priority?
- AAdminister the prescribed antipsychotic medication immediately立即給予處方的抗精神病藥物
- BAsk the client what the voices are saying in detail詳細詢問病人幻聽的內容
- CChallenge the reality of the voices挑戰幻聽的現實性
- DImplement suicide precautions and ensure safety✓ 正解實施自殺預防措施並確保安全
— Explanation · 中文詳解 —
護理的首要原則是維護病人安全。當病人出現命令式幻聽且威脅自我生命時，應立即執行自殺防範措施（Suicide precautions），包括一對一監控、移除危險物品。詳細詢問幻聽內容是其次，挑戰真實性則會破壞護病關係。
The foremost principle of nursing is to maintain patient safety. When a patient experiences command hallucinations threatening self-harm, suicide precautions must be implemented immediately, including one-to-one observation and removal of dangerous objects. Detailed questioning about the content of the hallucinations is secondary, and challenging their reality would damage the therapeutic relationship.
✦ 台美臨床差異
美台對於命令式幻聽皆視為精神科緊急狀況，台灣護理師執行約束或隔離需遵循嚴格法律規範。