A nurse is admitting a client who has schizophrenia.
The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?
A.
“Have you taken your medication today?”.
B.
“How long have you been hearing the voices?”.
C.
“What are the voices telling you?”.
D.
“I realize the voices are real to you, but I don’t hear anything.”.
E.
undefined
The Correct Answer and Explanation is :
The correct answer is:
C. “What are the voices telling you?”
Explanation:
When a client with schizophrenia reports hearing voices, it is crucial for the nurse to assess the content of the auditory hallucinations. This is the priority because the voices could be instructing the client to engage in harmful behaviors, such as self-harm or harming others. Auditory hallucinations can sometimes be commanding in nature, where the voices might direct the individual to commit dangerous acts. Understanding the nature of the voices can help the nurse determine whether the client is at immediate risk of harm and guide appropriate interventions.
Why this response is correct:
- Assessing risk: By asking, “What are the voices telling you?” the nurse gathers critical information that can indicate whether the hallucinations are benign (e.g., neutral or non-threatening) or if they are commanding the client to act in a harmful or dangerous way. If the voices are commanding, immediate intervention is required to ensure the safety of the client and others.
- Therapeutic communication: This question demonstrates that the nurse is taking the client’s experience seriously and is interested in understanding the details. It conveys empathy without validating or invalidating the hallucination. Instead, it focuses on the content, which is essential for risk assessment and care planning.
Why the other options are less appropriate:
- A. “Have you taken your medication today?”: While medication adherence is important, it is not the priority in this situation. The priority is to assess whether the hallucinations pose a risk to the client’s safety.
- B. “How long have you been hearing the voices?”: This question provides background information but does not address the immediate safety concern. The content of the voices is more urgent to determine the level of risk.
- D. “I realize the voices are real to you, but I don’t hear anything.”: While this statement validates the client’s feelings, it does not assess the immediate risk associated with the hallucinations.
In summary, assessing the content of the hallucinations is the priority to ensure the safety of the client and guide appropriate interventions.