— 心理社會完整性 · MEDIUM · MCQ —
一位精神科病房病人焦慮踱步並大喊：「政府在監控我的思想！」護理師應優先採取的介入措施為何？
A client in a psychiatric unit is pacing rapidly and shouting, 'The government is monitoring my thoughts!' Which intervention is the highest priority for the nurse?
- AChallenge the client's delusion by explaining that no one is listening.透過解釋沒有人正在聆聽來挑戰病人的妄想
- BEnsure the safety of the client and others while maintaining a calm environment.✓ 正解在維持安靜環境的同時，確保病人及他人的安全
- CRestrict the client to their room to decrease sensory stimulation.將病人限制在房間內以降低感官刺激
- DAdminister the prescribed PRN antipsychotic medication immediately.立即給予處方的備用抗精神病藥物
— Explanation · 中文詳解 —
面對急性躁動與妄想病人，維持安全是第一要務（Safety First）。護理師應營造冷靜的環境，防止傷害發生。A 需要醫師醫囑，且非首要步驟；A 對抗妄想無效且會增加衝突；D 隔離屬於限制身體自主權，需評估是否符合約束標準，非初始介入。
In psychiatric nursing, safety is the highest priority when a client exhibits acute agitation and delusions. The nurse must first ensure the safety of the client and others by maintaining a calm environment, rather than challenging the delusion or using restrictive measures immediately.
✦ 台美臨床差異
美國非常強調非約束（least restrictive environment）政策；台灣精神科對急性期病人使用保護室或約束的頻率較高，標準較寬鬆。