— 心理社會完整性 · HARD · MCQ —
患有精神分裂症的病人告訴護理師：「這些聲音告訴我應該停止服藥。」下列哪項回應最合適？
A client with schizophrenia tells the nurse, 'The voices are telling me that I should stop taking my medication.' Which response is most appropriate?
- AI don't hear any voices, you should ignore them.我聽不到任何聲音，你應該忽略它們。
- BYou need to continue your medication to keep the voices away.你需要繼續服藥以消除這些聲音。
- CWhat are the voices saying to you about the medication?✓ 正解關於藥物，這些聲音對你說了些什麼？
- DThe voices are not real, you are having a hallucination.這些聲音不是真的，你正在經歷幻覺。
— Explanation · 中文詳解 —
面對幻聽，護理師應保持非批判態度並評估內容（安全風險）。選項 C 鼓勵病人進一步溝通，同時評估幻聽指令的危險性。選項 A 和 D 直接否認病人的經驗，會破壞治療關係。選項 B 雖然正確，但帶有勸導色彩，缺乏對病人經驗的初步評估。
The most appropriate response is to assess the content of the command hallucinations to evaluate potential safety risks, such as self-harm or non-adherence to treatment. Validating the client's experience without arguing about its reality builds trust, whereas dismissing the voices or being overly directive fails to address the immediate clinical concern.
✦ 台美臨床差異
美國護理師強調病人自主與心理評估，台灣則常見因家屬介入較深，護理師需同時進行家屬教育。