— 心理社會完整性 · HARD · MCQ —
一位患有精神分裂症的病人告訴護理師：「收音機在叫我傷害自己。」護理師首要行動為何？
A client with schizophrenia tells the nurse, 'The radio is telling me to hurt myself.' Which is the most appropriate initial nursing action?
- AAssess the client's current safety status and risk✓ 正解評估病人當前的安全狀況與風險
- BAddress the underlying delusion處理潛在的妄想
- CInstruct the client to turn off the radio指示病人關閉收音機
- DAsk the client what the radio said詢問病人收音機說了什麼
— Explanation · 中文詳解 —
當病人表達受「命令式幻聽」（command hallucinations）影響時，首要考量為病人的人身安全。護理師需評估病人是否真的會遵從命令及採取行動，以預防自殺或自傷風險。評估風險後再決定後續的醫療與監測計畫。
When a client reports command hallucinations, the nurse's highest priority is to assess immediate safety and the risk of self-harm or suicide. Addressing the delusion directly or asking for details is secondary to ensuring the client's physical safety.
✦ 台美臨床差異
美國採取較嚴格的 suicide precaution 與 observation policy；台灣則在病房設計與約束政策上有較多臨床彈性。