一位住院精神科病患在走廊踱步並大喊：「政府透過通風口監視我的想法！」護理師應採取哪些處置？（選所有適合的）
A client in the inpatient psychiatric unit is pacing the hallway and shouting, 'The government is tracking my thoughts through the vents!' Which of the following nursing actions are appropriate? (Select all that apply.)
- AValidate the client's delusional experience to promote rapport驗證病人的妄想經驗以促進護病關係
- BFocus the conversation on reality-based topics✓ 正解將對話聚焦於基於現實的主題
- CAsk the client to explain the mechanisms behind the government tracking要求病人解釋政府追蹤背後的機制
- DMaintain a calm, low-stimulation environment✓ 正解維持平靜、低刺激的環境
- ESet firm, clear limits on aggressive or disruptive behavior✓ 正解對攻擊性或干擾行為設定堅定明確的限制
面對妄想型思考的病人，護理原則是『不參與妄想、不挑戰妄想、引導回現實』。選項 A 的驗證會強化病人的妄想體系，導致病程惡化。選項 C 則是誘導病人深入解析妄想，同樣不正確。正確的做法應是將焦點放在現實感受與當前安全上（B）。營造低刺激環境（D）能降低病人對環境的防備與過度警覺。同時，針對其干擾性行為（大聲喧嘩、侵犯空間）應設立明確的界限（E），告知病人哪些行為不被接受，保護其餘病人和工作人員的安全。此情境強調治療性溝通的界限與安全管理。
When a client exhibits paranoid delusions, the nurse should focus on reality-based topics and maintain a calm, low-stimulation environment to reduce agitation. It is important to set firm limits on disruptive behavior to ensure safety, while avoiding validating or exploring the delusions, which can reinforce the distorted thinking.
美國精神科護理強調「行為契約」（Behavioral Contract）與環境治療，護理師被賦予更多自主權設置治療性界限；台灣臨床多偏向給予藥物控制衝動，且受限於病房過度擁擠，較難維持理想的低刺激環境。