# 一位思覺失調症病人說：「聲音又在爭論我的事了。」護理師應如何回應？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=498894&lang=zh-tw > language: zh-TW > subject: Adverse Effects/Contraindications/Interactions > category: PSI ## 題目 一位思覺失調症病人說：「聲音又在爭論我的事了。」護理師應如何回應？ ## 選項 1. 我聽不到那些聲音，但我知道這讓你很困擾；它們在對你說什麼？ **✔ 正確答案** 2. 試著忽略那些聲音，加入團體活動，不要討論你聽到的內容 3. 想想看你可能做了什麼事，導致那些聲音開始爭論 4. 那些聲音來自你的疾病，所以它們現在無法指示你做任何有害的事 **正確答案: 1** ## 解析 護理師在不確認幻覺的情況下承認病人的困擾，陳述現實，並評估聲音內容以確保安全。命令性內容或威脅需要立即進行風險評估和保護措施。 ## 深入解析 快速解答 呈現現實，確認病人的困擾，並評估聲音確切在說什麼。 為什麼這是正確的 治療性回應既不認同聲音來自外界，也不因病人聽到聲音而羞辱他。詢問內容可識別命令、威脅或升高的風險，並幫助護理師規劃立即的安全支持。 簡單比喻或心智圖像 護理師站在堅實的地面上，詢問病人的內在警報正在報告什麼。這個比喻強調現實和評估，但並不暗示幻覺是自願的或不重要的。 記憶掛鉤 幻覺回應：現實、感受、內容、安全。 NCLEX 決策規則 當病人報告幻覺時，陳述自己的現實而不爭論，承認情緒，並評估內容和意圖。將命令性幻覺或威脅視為直接的安全問題。 為什麼其他選項是錯的 忽略報告會錯失風險評估。責怪病人會增加羞恥感，而假設聲音無法指示有害行為則錯誤地輕忽了可能的命令性內容。參考文獻 - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]SchizophreniaNational Institute of Mental Health ## 相同主題題目 - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=zh-tw) - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=zh-tw) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=zh-tw) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=zh-tw) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=zh-tw) - [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=zh-tw) - [An 80-year-old male with heart failure is prescribed digoxin 0.125 mg daily. During mornin…](https://mymerci.kr/pages/nclex_q.php?qn_id=372686&lang=zh-tw) - [A 38-year-old female with rheumatoid arthritis is being discharged with a new prescription…](https://mymerci.kr/pages/nclex_q.php?qn_id=372687&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=498894&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=498894&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=498894&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=498894&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=498894&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_