護理師與一位病人互動，病人說：「我是美國總統，每個人都必須服從我。」下列哪項護理回應具治療性？
The nurse is interacting with a client who says, 'I am the President of the United States, and everyone must obey me.' Which response by the nurse is therapeutic?
- ANo, you are not the President; you are a patient in a hospital.不，你不是總統；你是一名醫院病人。
- BIt must be stressful to have so much responsibility as a leader.身為領導者承擔如此多的責任一定很有壓力。
- CI am a nurse, and I am here to help you with your medications.✓ 正解我是護理師，我來這裡幫助你服用藥物。
- DCan you tell me more about your political platform?你能告訴我更多關於你的政治綱領嗎？
面對誇大妄想（Grandiose Delusion），護理師應採取「呈現現實」（Presenting Reality）與「聚焦當下」的策略。選項 C 溫和地指出護理師的真實身份與目前的活動（給藥），不直接挑戰妄想也不捲入其中。選項 A 太過直接對抗，可能導致病人防禦；B 承認了妄想內容；D 則是鼓勵妄想，皆非合宜做法。
A therapeutic response to grandiose delusions involves gently presenting reality without directly challenging the client’s belief or reinforcing the delusion. By stating their own role and focusing on immediate tasks, such as medication administration, the nurse helps ground the client in the present moment, avoiding engagement with the false narrative.
美國護理強調「Not challenging the delusion」但「Presenting reality」；台灣臨床教導類似，但有時會併用同理感受（如選項 B 的技巧，但在 NCLEX 中 B 通常被視為認可妄想）。