NurslixJournal
心理社會完整性 · HARD · SATA

一位患有思覺失調症的客戶出現聽幻覺,護理師應包含哪些護理計畫?(選所有適合的)

A nurse is assessing a client with schizophrenia who is experiencing auditory hallucinations. Which interventions should the nurse include in the plan of care? (Select all that apply.)

  • AAsk the client what the voices are saying✓ 正解
    詢問病人聲音在說什麼
  • BMaintain a consistent daily routine✓ 正解
    維持一致的日常作息
  • CValidate the client's experience by agreeing that the voices are real
    透過同意聲音是真實的來驗證病人的經驗
  • DEngage the client in structured social activities✓ 正解
    讓病人參與結構化的社交活動
  • EMinimize stimuli in the environment✓ 正解
    減少環境中的刺激
Explanation · 中文詳解

思覺失調症(Schizophrenia)病人的聽幻覺(Auditory hallucinations)可能包含命令性幻聽(Command hallucinations),具有傷害自己或他人的潛在風險。護理原則是探究內容以評估安全、維持環境結構以減少混亂、鼓勵現實導向活動以轉移注意力。切記不可附和幻聽,這會加強病人對幻覺的真實感,延誤治療。

Assessing the content of auditory hallucinations is crucial for safety, particularly to identify command hallucinations that may pose a risk of harm. Providing a consistent routine and minimizing environmental stimuli helps reduce anxiety and overstimulation, while engaging the client in structured activities offers distraction from the hallucinatory experience. Nurses must avoid validating the hallucinations as real, as this reinforces the psychotic process.

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