— 心理社會完整性 · HARD · SATA —
一位患有思覺失調症的病人出現聽幻覺，且焦躁不安情形日益嚴重。護理師應優先採取哪些措施以確保安全？（選所有適合的）
A client with schizophrenia is experiencing auditory hallucinations and is becoming increasingly agitated. Which actions should the nurse prioritize to ensure safety? (Select all that apply.)
- AMaintain a calm and non-threatening demeanor✓ 正解保持鎮定且無威脅性的態度
- BDecrease external sensory stimuli✓ 正解減少外部感官刺激
- CArgue with the client to disprove the hallucinations與病人爭辯以駁斥幻覺
- DEnsure the client is never left alone in the room確保病人獨處房間時有人陪同
- EAssess the client for command hallucinations✓ 正解評估病人是否有命令型幻覺
— Explanation · 中文詳解 —
思覺失調症病人出現幻覺時，護理重點為維護安全並降低過度刺激。評估是否具備「指令型幻覺」是防止暴力或自傷的關鍵。A 與 B 可營造低刺激環境，降低 agitation。C 為錯誤行為，辯論會強化病人防衛；D 應考量隱私與安全平衡，過度干涉可能引發抗拒，重點應是觀察而非全時伴隨。
To ensure safety and reduce agitation, the nurse should maintain a calm demeanor, decrease environmental stimuli, and assess for command hallucinations that could lead to harm. Arguing with the client about the reality of hallucinations is ineffective and may increase distress.
✦ 台美臨床差異
美國護理界對於暴力預防有嚴格的行為規範（De-escalation protocols），台灣臨床則常依賴照服員或家屬協助觀察。