— 心理社會完整性 · EASY · MCQ —
護理師照護一位有聽幻覺的思覺失調症病人，哪項護理措施最適當？
A nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which nursing intervention is most appropriate?
- AAsk the client what the voices are saying to them.✓ 正解詢問個案那些聲音對他們說了什麼。
- BChallenge the client's perception to test reality.挑戰個案的感知以測試現實。
- CIgnore the client until the voices stop.忽略個案直到聲音停止。
- DTell the client that the voices are not real.告訴個案那些聲音不是真的。
— Explanation · 中文詳解 —
面對幻覺，護理師應評估其內容，特別是命令性幻覺（Command Hallucinations），以確認個案是否有傷害自己或他人的危險。直接否定其幻覺會破壞治療聯盟，應轉移焦點至現實活動，而非爭辯幻覺的真實性。
When a client experiences auditory hallucinations, the nurse should assess the content of the voices, particularly checking for command hallucinations that may pose a safety risk. Challenging the client’s reality or ignoring the symptoms is non-therapeutic, whereas assessing for danger supports safety and maintains the therapeutic alliance.
✦ 台美臨床差異
台美均強調保護性評估；台灣臨床較常由主治醫師判定是否增加 antipsychotics 劑量。