A practical nurse (PN) is reinforcing medication teaching for a client with a history of schizophrenia. The client has a flat affect and appears unkempt. While the PN is speaking, the client abruptly stops listening, tilts their head to the side, and stares intently at an empty corner of the room. Which action should the PN take first?
- AReach out and gently touch the client's arm to redirect their attention to the medication teaching.
- Ask the client directly, "Are you hearing voices right now, and what are they telling you?"Answer
- CAsk the client, "Why are you staring at the wall instead of listening to the instructions?"
- DReassure the client by stating, "You are safe in this clinic, and there is no one else in the room."
Answer
Ask the client directly if they are hearing voices and what the voices are saying.
The client's nonverbal cues—abruptly stopping conversation, tilting the head, and intensely staring—strongly suggest they are experiencing active auditory hallucinations. The immediate priority for the practical nurse is to ensure safety by determining if the voices are command hallucinations (voices instructing the client to harm themselves or others). Directly asking the client about the voices and their content is the most appropriate and essential data collection action within the PN scope of practice.
Step-by-Step Solution
Key Concept
Assessment and Management of Auditory Hallucinations
Estimated Time:1m 0s