— 心理社會完整性 · MEDIUM · SATA —
護理師觀察到一位思覺失調症病人正在與空氣對話（幻聽）。護理師應採取哪些措施？（選所有適合的）
A nurse observes a client with schizophrenia talking to someone who is not there. Which actions are appropriate for the nurse to take? (Select all that apply.)
- AAsk the client what the voices are saying✓ 正解詢問病人聲音在說什麼
- BTell the client that the voices are not real告訴病人聲音不是真實的
- CFocus on the feelings associated with the voices✓ 正解聚焦於與聲音相關的感受
- DRedirect the client to a reality-based activity✓ 正解將病人引導至基於現實的活動
- ERefuse to acknowledge the voices to discourage them拒絕承認聲音的存在以使其消退
— Explanation · 中文詳解 —
處理幻聽（Auditory hallucinations）的護理原則是「安全為先、現實導向」。護理師應先評估幻聽內容，確認是否包含命令型幻覺（Command hallucinations）以評估自傷或傷人風險。面對幻聽時，護理師不應挑戰其真實性，因這對病人而言是真實經驗，反之應轉移焦點至其背後的情緒感受，並引導病人參與現實活動，以減少對幻覺的專注。
The nurse should assess the content of the hallucinations to evaluate for command hallucinations that pose a safety risk. It is therapeutic to focus on the client’s feelings rather than confronting the reality of the voices, which can increase agitation. Redirecting the client to reality-based activities helps reduce the focus on the hallucination.