— 心理社會完整性 · MEDIUM · SATA —
一位思覺失調症個案出現聽幻覺，護理師的照護計畫應包含哪些？（選所有適合的）
A client with schizophrenia is experiencing auditory hallucinations. Which action should the nurse include in the plan of care? (Select all that apply.)
- AMaintain a quiet environment to reduce external stimuli✓ 正解維持安靜環境以減少外在刺激
- BAsk the client what the voices are saying✓ 正解詢問病人聲音的內容為何
- CArgue with the client that the voices are not real與病人爭辯聲音並非真實存在
- DEncourage the client to engage in reality-based activities✓ 正解鼓勵病人參與基於現實的活動
- EAvoid talking about the hallucinations to prevent reinforcement避免討論幻覺以防強化症狀
— Explanation · 中文詳解 —
針對聽幻覺個案，重點在於評估幻聽內容（確認是否有攻擊指令）、減少環境刺激，並轉移注意力至現實活動。爭辯幻覺的真實性會損害信任關係，而忽略不談則會錯失評估傷害風險的機會。建立穩定、無威脅性的溝通氛圍是照護的首要任務。
Nursing care for auditory hallucinations involves assessing the content of the voices to evaluate for command hallucinations that may pose a safety risk. Interventions should include maintaining a quiet environment to reduce stimuli and encouraging engagement in reality-based activities to help ground the client.
✦ 台美臨床差異
美台對於幻聽的處理原則相似，皆以提升安全性與現實感為目標，並強調評估指令型幻聽。