— 心理社會完整性 · HARD · MCQ —
一位思覺失調症病患正經歷幻聽，告訴護理師：「聲音叫我去傷害自己。」護理師的首要行動為何？
A client with schizophrenia is experiencing auditory hallucinations. The client tells the nurse, 'The voices are telling me to hurt myself.' What is the nurse's priority action?
- AExplain to the client that the voices are not real.向個案解釋聲音並非真實存在
- BInitiate suicide precautions and ensure safety.✓ 正解啟動防自殺 precautions 並確保安全
- CAsk the client what the voices sound like.詢問個案聲音聽起來像什麼
- DPlace the client in a quiet room to reduce stimulation.將個案安置於安靜的房間以減少刺激
— Explanation · 中文詳解 —
當病患出現命令式幻聽且涉及自我傷害時，安全永遠是第一優先。護理師必須立即採取自殺防範措施（如移除危險物品、加強監視），而非探索幻聽內容或進行現實感導向（Reality Testing）。優先預防傷害發生是緊急護理的關鍵。
When a client with schizophrenia experiences command hallucinations involving self-harm, safety is the absolute priority. The nurse must immediately initiate suicide precautions to protect the client, rather than exploring the hallucinations or challenging their reality, which could escalate the risk of harm.
✦ 台美臨床差異
美國法規對於強制住院與自殺風險評估有極嚴格的文書要求；台灣則多採取家屬共同照顧模式。