— 心理社會完整性 · MEDIUM · SATA —
護理師為一位患有思覺失調症且有聽幻覺的個案規劃護理計畫，下列哪些措施合適？（選所有適合的）
A nurse is planning care for a client with schizophrenia who is experiencing auditory hallucinations. Which interventions should the nurse include in the care plan? (Select all that apply.)
- AAcknowledge the client's experience without validating the hallucination✓ 正解肯定病人的經驗，但不確認幻覺的真實性
- BMaintain a low-stimulation environment to minimize triggers✓ 正解維持低刺激的環境以減少誘發因素
- CEncourage the client to listen to the voices to find meaning鼓勵病人聆聽聲音以尋找意義
- DUse direct, simple communication when speaking to the client✓ 正解與病人交談時使用直接且簡單的溝通方式
- EFocus the client on reality-based topics and activities✓ 正解引導病人關注基於現實的主題與活動
— Explanation · 中文詳解 —
針對思覺失調症（Schizophrenia）的聽幻覺（Auditory hallucinations），核心護理原則是「不強化幻覺真實性，但承認個案的主觀感受」。護理師應透過現實導向（Reality orientation）將個案帶回當下，並減少環境刺激以降低幻覺誘發因子，同時使用簡單指令以避免個案因認知負荷過重而混亂。
The nurse should acknowledge the client’s feelings without validating the hallucinations to maintain a therapeutic relationship while grounding the client in reality. Interventions include maintaining a low-stimulation environment to reduce triggers, using direct and simple communication to minimize cognitive overload, and focusing on reality-based activities.