A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today…they are so angry with me." Which of the following is the best response by the nurse?

Question

Quizplus · Accepted Answer

The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command auditory hallucinations that could lead to self-directed or other-directed injury and harm. After the content of the hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence. Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any of the 5 senses. Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory (smell), and gustatory (taste). Additional ways to deal with hallucinations include the following: Telling the client that you know they are real to the client but that you do not hear the voices (or see the vision, feel the sensation) Not arguing with or challenging the client about the hallucinations Directing the client to a reality-oriented topic of conversation or activity (Option A) An antianxiety medication may be needed if the voices are causing this client to become increasingly distressed. Assessment is needed before choosing this option. (Option B) This choice dismisses this client's concerns about the nature of the voices. (Option C) Telling the voices to "go away" (voice dismissal) is a technique that some clients find effective in management of hallucinations. It is not the priority nursing action in this client. Educational objective: It is important for the nurse to initially explore the content of a client's hallucinations to assess the risk for harm and/or injury and determine appropriate interventions. The nurse can tell the client that the nurse knows the voices are real to the client but are not heard by the nurse. The client with hallucinations should be directed to reality-oriented activities rather than to further discussion of the content of the hallucinations.

A Client Recently Diagnosed with Schizophrenia Is Hospitalized