A client with schizophrenia is seen sitting alone and talking out loud. Suddenly, the client stops and turns as if listening to someone. The nurse approaches and sits down beside the client. Which of the following is the best initial response by the nurse?

Question

Quizplus · Accepted Answer

Intervening when the client experiences hallucinations requires the nurse to focus on what is real and to help shift the client's response toward reality. Initially, the nurse must determine what the client is experiencingóthat is, what the voices are saying or what the client is seeing. In command hallucinations, the client hears voices directing him or her to do something, often to hurt self or someone else. For this reason, the nurse must elicit a description of the content of the hallucination so that health-care personnel can take precautions to protect the client and others as necessary. The nurse might say, I don't hear any voices; what are you hearing? How long have you known the person you are talking to? would reinforce the client's hallucination.

A Client with Schizophrenia Is Seen Sitting Alone and Talking