A nurse in an inpatient psychiatric unit is caring for a client with schizophrenia who is actively experiencing distressing auditory hallucinations. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)
- Ask the client directly what the voices are saying.Answer
- Acknowledge the client's fear while stating that the nurse does not hear the voices.Answer
- CDelegate the task of evaluating the client's risk for self-harm to an unlicensed assistive personnel (UAP).
- Decrease environmental stimuli by turning off the television and minimizing loud noises in the room.Answer
- EAgree with the client that the voices are present in the room to quickly establish a therapeutic alliance.
- FApply physical restraints immediately to prevent injury if the client begins pacing anxiously.
Answer
The correct interventions are to ask the client directly what the voices are saying, acknowledge the client's fear while stating the nurse does not hear the voices, and decrease environmental stimuli.
Appropriate care for a client experiencing auditory hallucinations involves ensuring safety by assessing for command hallucinations, using therapeutic communication to present reality while validating emotions, and modifying the environment to reduce sensory overload.
Step-by-Step Solution
Key Concept
Nursing Management of Auditory Hallucinations