— 心理社會完整性 · HARD · MCQ —
一位思覺失調症個案表示聽見命令其傷害他人的幻聽。下列何者為護理師最高優先級的行動？
A client with schizophrenia reports hearing voices that command them to hurt others. Which nursing action is the highest priority?
- AInitiate a one-to-one observation to ensure client and staff safety✓ 正解啟動一對一監護以確保病人及人員安全
- BProvide a quiet, low-stimulation environment for the client為病人提供安靜、低刺激的環境
- CAdminister the prescribed antipsychotic medication immediately立即給予處方之抗精神病藥物
- DAsk the client what the voices are saying in more detail詳細詢問病人幻聽的內容
— Explanation · 中文詳解 —
此個案出現命令性幻聽，且內容涉及傷害他人，此時護理師的最高指導原則是安全。實施一對一隨身監測能確保個案不傷害自己或他人，並能即時監控行為變化。給藥雖重要，但需先防範暴力行為；深入詢問幻聽內容應由醫師或心理師評估；提供安靜環境是輔助措施，非優先處置。
The highest priority is initiating one-to-one observation to ensure the safety of the client and others, given the presence of command hallucinations involving harm. While administering medication and providing a quiet environment are important interventions, immediate physical supervision is essential to prevent potential violent behavior.
✦ 台美臨床差異
美台在處理暴力風險個案時，皆依循「病人及環境安全」原則，但美國在執行一對一監測時常有特定人力配比規範。