一名患有思覺失調症的個案表示「幻聽叫我跳窗」。護理師的優先處置為何？
A client with schizophrenia is experiencing auditory hallucinations, stating that 'the voices are telling me to jump out of the window.' What is the nurse's priority action?
- ATell the client the voices are not real告訴個案這些聲音不是真實的
- BMaintain safety and implement one-to-one supervision✓ 正解維持安全並實施一對一監護
- CAsk the client why they feel the need to obey the voices詢問個案為何覺得需要服從這些聲音
- DPlace the client in a quiet, low-stimulation environment將個案安置於安靜、低刺激的環境中
此個案呈現命令式幻聽，具有高度自我傷害風險。護理師的最高指導原則是維護個案生命安全，透過一對一監護確保其無法執行傷害行為。否定幻聽真實性無效且會破壞信任，降低刺激雖重要但屬次要保護措施，探討原因則無法緩解迫在眉睫的危險。
This client is experiencing command hallucinations and is at high risk for self-harm. The nurse's overriding principle is to safeguard the client's life by providing one-to-one observation to ensure the client cannot act on the harmful command. Directly denying the reality of the hallucinations is ineffective and undermines trust; reducing environmental stimulation, while important, is a secondary protective measure; exploring the reasons for the behavior does not address the imminent danger.
兩地皆重視 suicide precaution。美國更強調利用行為守則（behavioral contract）作為輔助，台灣則極度倚重物理隔離或持續監護。