A client with a history of schizophrenia is receiving care on a general medical unit for a systemic infection. While the licensed practical nurse is reinforcing teaching about oral antibiotics, the client suddenly covers both ears, becomes visibly distressed, and states, "The voices are telling me to pull this intravenous line out." Which action should the nurse take next?
- Ask the client directly if the voices are commanding them to perform any other harmful actions.Answer
- BReassure the client by stating, "There is no one else in the room speaking, so you are perfectly safe here."
- CImmediately apply bilateral soft wrist restraints to prevent the client from dislodging the vascular access device.
- DAdminister an intravenous push dose of a prescribed PRN antipsychotic medication to rapidly manage the acute hallucination.
Answer
Ask the client directly if the voices are commanding them to perform any other harmful actions.
When a client experiences auditory hallucinations that dictate specific actions (command hallucinations), the immediate priority is client and staff safety. The nurse must directly ask what the voices are saying to collect accurate data about the risk of self-harm, violence, or medical non-adherence. This focused, immediate data collection falls firmly within the practical nurse's scope and allows the healthcare team to quickly implement necessary safety precautions.
Step-by-Step Solution
Key Concept
Command Hallucinations and Practical Nurse Scope of Practice