— 心理社會完整性 · HARD · MCQ —
一位思覺失調症病人聽見幻聽並表示：「聲音叫我去傷害別人。」護理師應優先採取什麼行動？
A client with schizophrenia is experiencing auditory hallucinations, stating, 'The voices are telling me to hurt someone.' Which action should the nurse take first?
- AAdminister the scheduled dose of antipsychotic medication給予預定劑量的抗精神病藥物
- BAsk the client what the voices are saying詢問病人聲音說了什麼
- CDiscuss the reality of the voices with the client與病人討論聲音的現實性
- DIncrease the client's observation level to ensure safety✓ 正解提高對病人的觀察等級以確保安全
— Explanation · 中文詳解 —
面對出現命令性幻聽（Command Hallucinations）且內容涉及傷害他人的病人，護理師的安全評估優先級高於一切。必須立即採取保護措施，如增加觀察頻率（One-to-one observation），以防止病人付諸行動。在確認安全之前，不宜過度探索幻聽內容或與其爭辯真實性，以免引發病人焦慮或防衛行為。
When a client with schizophrenia expresses command hallucinations to harm others, ensuring safety is the highest priority. The nurse must immediately increase observation levels, such as implementing one-to-one monitoring, to prevent impulsive acts. Interventions like challenging the hallucinations or gathering detailed information should be deferred until the client is stabilized and safe.