— 心理社會完整性 · MEDIUM · MCQ —
護理師正在收納一位報告聽見聽幻覺的病人。病人說：「我聽見聲音說我很沒價值。」最恰當的護理介入措施是什麼？
A nurse is admitting a client who reports experiencing auditory hallucinations. The client states, 'I hear voices telling me I am worthless.' What is the MOST appropriate nursing intervention?
- AAdminister a PRN sedative.給予處方用藥（PRN）鎮靜劑。
- BTell the client the voices are not real.告訴病人那些聲音不是真的。
- CEncourage the client to focus on the content of the voices.鼓勵病人專注於聲音的內容。
- DAssess the client for suicidal ideation.✓ 正解評估病人是否有自殺意念。
— Explanation · 中文詳解 —
當病人聽到貶低自己的幻聽（Command Hallucinations），這與低自尊、自我價值感低落有高度相關，且這類聲音常會命令病人傷害自己。因此，護理師的首要任務是評估病人的「自殺風險（Suicidal Ideation）」。安全永遠是護理的第一優先（Safety First），在確認病人是否有自我傷害意念前，不應忽視這些聲音的潛在危險性。
Auditory hallucinations commanding the client as worthless pose a significant risk for self-harm or suicide. Safety is the nursing priority, so the immediate intervention must be to assess for suicidal ideation before addressing the hallucinations with other methods.