— 心理社會完整性 · MEDIUM · MCQ —
護理師觀察到一名思覺失調症個案在走廊來回踱步，對著虛無對象說話，並顯得煩躁。哪項護理措施最合適？
A nurse observes a client with schizophrenia pacing in the hallway, talking to invisible individuals, and appearing agitated. Which nursing action is most appropriate?
- AAdminister an antipsychotic medication immediately立即給予抗精神病藥物
- BFocus on the client's current feelings rather than the hallucinations✓ 正解聚焦於病人當下的感受，而非幻覺
- CAsk the client what the voices are saying詢問病人聲音說了什麼
- DTell the client that no one else is there告訴病人那裡並沒有其他人
— Explanation · 中文詳解 —
面對思覺失調症病人出現幻覺（Hallucinations）時，護理師應採取「不認同、不爭辯、轉移焦點」的溝通原則。直接否認病人的幻覺（如說「那裡沒有人」）會破壞治療性關係，引發病人的防衛心或憤怒。護理師應將對話導向病人當下的感受（如焦慮、害怕），這有助於緩解病人的情緒，並進一步評估其是否有危險行為。
When a client with schizophrenia experiences hallucinations, the nurse should avoid challenging the reality of the experience, as this can damage the therapeutic relationship. Instead, the nurse should focus on the client's underlying emotions, such as anxiety or fear, to help de-escalate agitation and address the distress without validating the hallucination.