— 心理社會完整性 · MEDIUM · MCQ —
一位思覺失調症個案出現幻聽，下列哪項護理措施最有效？
A client with schizophrenia is experiencing auditory hallucinations. Which nursing action is most effective?
- ATell the client that they are just imagining things告訴個案他們只是在想像
- BAsk the client what the voices are telling them to do✓ 正解詢問個案聲音告訴他們做什麼
- CAgree with the client that the voices are real to avoid conflict同意個案聲音是真實的以避免衝突
- DChange the subject to distract the client轉移話題以分散個案注意力
— Explanation · 中文詳解 —
護理師應針對幻聽進行評估（Assessment），特別是幻聽內容是否涉及命令性幻聽（Command Hallucinations），因為這與暴力行為風險高度相關。不能附和幻聽（C），也不應直接否定（A），轉移話題（D）則可能錯失評估風險的機會。
When a client with schizophrenia experiences auditory hallucinations, the nurse must assess for command hallucinations to evaluate safety risks. Confronting, agreeing with, or distracting from the hallucinations is non-therapeutic and fails to address potential danger.
✦ 台美臨床差異
美國護理師在評估幻聽時非常強調「安全契約」與「暴力風險評估表（如 HCR-20）」，台灣臨床則多由精神專科醫師主導判斷。