Comprehensive exams for Mental Health Q 101
The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn’t visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate?
A. Approach the client and touch him to get his attention.
B. Encourage the client to go to his room where he’ll experience fewer distractions.
C. Acknowledge that the client is hearing voices but make it clear that the nurse doesn’t hear these voices.
D. Ask the client to describe what the voices are saying.
Correct Answer: C. Acknowledge that the client is hearing voices but make it clear that the nurse doesn’t hear these voices.
By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn’t hear the voices, the nurse avoids reinforcing the hallucination. Auditory hallucinations are the sensory perceptions of hearing voices without an external stimulus. This symptom is particularly associated with schizophrenia and related psychotic disorders but is not specific to it. Auditory hallucinations are one of the major symptoms of psychosis.
Option A: The nurse shouldn’t touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently.
Option B: Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client.
Option D: By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client’s feelings, rather than the content of the hallucination.