— 心理社會完整性 · MEDIUM · MCQ —
一位思覺失調症病人正在走廊踱步並對著不存在的聲音大吼。哪項護理措施是優先的？
A client with schizophrenia is pacing the hallway and yelling at voices that are not present. Which nursing action is the priority?
- AProvide a quiet environment with minimal stimulation.✓ 正解提供安靜且刺激最小化的環境。
- BAsk the client what the voices are saying.詢問病人聲音在說什麼。
- CAdminister PRN antipsychotic medication.給予備用抗精神病藥物。
- DAttempt to reorient the client to reality.嘗試將病人導回現實。
— Explanation · 中文詳解 —
針對幻聽與激動行為，首要任務是維持病人與環境的安全。將病人引導至低刺激環境能減少感官過載，降低其焦慮與激動程度。A 需要醫師醫囑；B 雖然重要以評估指令性幻覺，但在病人高度激動時並非首選；D 對於急性期幻覺病人通常無效，反而可能引發衝突。
The priority nursing action is to reduce environmental stimuli by providing a quiet setting, which helps decrease sensory overload and agitation associated with auditory hallucinations. While assessing the content of voices and administering medication are important, they follow initial environmental safety measures. Reorientation is typically ineffective during acute psychosis and may increase distress.
✦ 台美臨床差異
美國 psychiatric unit 強調環境物理限制；台灣因人力比問題，常依賴約束或高劑量抗精神病藥物來控制躁動。