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Question

Difficulty: MediumSensory and Perceptual Alterations

A nurse is conducting an admission assessment on a client with a history of schizophrenia. During the interview, the client abruptly stops speaking mid-sentence, tilts their head to the side, and begins whispering as if responding to an unseen presence. Which action is the priority for the nurse to take?

  1. Ask the client directly what they are hearing.Answer
  2. B
    Tell the client that there is no one else present in the room.
  3. C
    Instruct an unlicensed assistive personnel to remain in the room with the client.
  4. D
    Document the behavior and continue with the standard admission questions.

Answer

The priority action is to ask the client directly what they are hearing to evaluate for the presence of command hallucinations.
When a client exhibits behavioral cues associated with auditory hallucinations, the priority is to assess the content of those hallucinations. Command hallucinations can direct the client to perform dangerous acts, posing a severe risk to themselves or others. Direct questioning is necessary to determine if immediate safety interventions are required.

Step-by-Step Solution

1
Analyze the client's behavioral cues.
The client stopping mid-sentence, tilting their head, and whispering strongly indicates they are experiencing active auditory hallucinations.
Recognizing the clinical signs of a perceptual alteration is essential to formulate a safe and targeted response.
2
Determine the highest priority need based on the assessment.
The immediate priority is to ensure safety by identifying the content of the hallucinations.
Auditory hallucinations can take the form of command hallucinations, which may instruct the client to harm themselves or others.
3
Select the appropriate therapeutic intervention.
The nurse must directly ask the client what the voices are saying.
Direct questioning is the only reliable way to assess the risk level and determine if immediate safety protocols must be initiated.

Key Concept

Assessing Command Hallucinations
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Topics

Sensory and Perceptual Alterations

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