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Question

Difficulty: EasySensory and Perceptual Alterations

The nurse is caring for a client on the inpatient psychiatric unit who is actively experiencing auditory hallucinations. Which actions should the nurse implement? Select all that apply.

  1. Ask the client directly what the voices are saying to determine safety risks.Answer
  2. B
    Instruct the Unlicensed Assistive Personnel (UAP) to assess the client's coping strategies.
  3. Acknowledge that the voices feel real to the client while stating that the nurse does not hear them.Answer
  4. D
    Pretend to hear the voices to build trust and rapport with the client.
  5. Provide a structured, quiet environment with reduced sensory stimulation.Answer
  6. F
    Argue with the client by explaining logically why the voices cannot be real.

Answer

The correct actions are asking what the voices are saying, acknowledging the client's experience while presenting reality, and providing a reduced-stimulation environment.
The correct nursing actions prioritize safety, therapeutic communication, and a healing environment. Directly asking about the voices is critical to assess for command hallucinations. Presenting reality without arguing grounds the client, and reducing environmental stimuli helps calm the sensory overload that often accompanies acute psychosis.

Step-by-Step Solution

1
Prioritize client safety by evaluating the content of the sensory alterations.
Asking the client directly about the voices identifies potential command hallucinations that could lead to self-harm or violence.
Safety is always the primary focus when a client is experiencing acute perceptual alterations.
2
Identify therapeutic versus non-therapeutic communication techniques.
Presenting reality while validating the client's feelings is therapeutic. Arguing or pretending to hear the voices is non-therapeutic.
Therapeutic communication builds trust without reinforcing the hallucination.
3
Evaluate environmental interventions.
Providing a quiet, structured environment reduces sensory overload.
Excessive stimuli can exacerbate sensory and perceptual alterations.
4
Review the scope of practice for delegation.
Recognize that assessing coping strategies requires nursing judgment and must be done by the RN, not the UAP.
Delegation of assessments to UAP violates the RN scope of practice.

Key Concept

Therapeutic Management of Auditory Hallucinations
Estimated Time:1m 30s
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Topics

Sensory and Perceptual Alterations

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