Question

A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, I hear voices telling me what to do. Which of the following actions should the nurse take?

A) Ignore the client's statement and focus on other admission procedures.
B) Ask the client to describe the voices and their commands in detail.
C) Reassure the client that everything will be fine and leave the room.
D) Document the client's statement and inform the healthcare provider during rounds.

Answer 1

The nurse should ask the client to describe the voices and their commands in detail, as this helps assess the mental state and plan appropriate care. Subsequently, documenting the client's statements and informing the healthcare provider are crucial steps.

Step-by-step explanation:

When a patient reports experiences like hearing voices, it's crucial to take a comprehensive approach to understand the nature of the auditory hallucinations and to assess the patient's mental state. As a nurse admitting a client who is anxious and hearing voices, the most appropriate action to take is option B: Ask the client to describe the voices and their commands in detail. This inquiry is not only necessary for accurate diagnosis and treatment planning but also shows the patient that they are being heard and taken seriously. It is part of the nursing assessment process, which helps determine the patient's mental status, potential risk factors, and the need for any immediate intervention.

The next steps would include documenting the client's statements in detail and communicating this information to the healthcare provider as soon as possible, as in option D. This ensures that the care team is aware of the client's condition and can provide appropriate care. A thorough assessment and prompt documentation are essential in the treatment of mental health concerns and for developing an individualized care plan for a patient experiencing symptoms such as auditory hallucinations.

Answer 2

A nurse in a mental health unit should listen attentively, document, and report to the healthcare provider when a client mentions that they hear voices, as this can be indicative of an underlying psychiatric condition (option D).

Step-by-step explanation:

The subject of this question is a mental health unit and it involves a client who reports that they hear voices. The correct action for a nurse in this situation would be to take the client’s statement seriously and to gather more information about the client's auditory hallucinations. According to standard mental health practices, the nurse should:

1. Listen to the client's experiences attentively without judgment.
2. Ask the client to describe the voices and what they are saying to gain a better understanding of the client's mental state.
3. Document the client's statements meticulously in their medical record.
4. Inform the mental health team, including the healthcare provider, as soon as possible to ensure appropriate follow-up and interventions.

It's critical to address hallucinations in a clinical setting with sensitivity and prompt attention, as they can be indicative of underlying psychiatric conditions that may require immediate intervention.

Hence, the answer is option D.