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. Tell the client that the voices do not really exist
b. Touch the client to help reduce feelings of anxiety
c. Instruct the client to go to a quiet room when the voices start talking
d. Ask the client what the voices are saying

Answer 1

In response to a client who reports hearing voices, the most appropriate nursing action is to ask the client what the voices are saying. This response respects the client's experience and provides important information for their care plan while avoiding dismissal or potentially inappropriate physical contact.

Step-by-step explanation:

Responding to a Client With Auditory Hallucinations

When a client is admitted to a mental health unit expressing that they are hearing voices, it is essential to approach the situation with care and professionalism. In this scenario, the most appropriate action the nurse can take is d. Ask the client what the voices are saying. This approach acknowledges the client's experiences without invalidating them, while also gathering important information that could be critical for their care plan. Moreover, asking about the content of the hallucinations can help assess for any potential risks to the client or others, if the voices are instructing harmful behavior.

Option (a) is not advisable because it dismisses the client's reality. Option (b) might be inappropriate without prior consent or establishing trust, as touch can be comforting to some but intrusive or disturbing to others. Option (c), instructing the client to go to a quiet room, can be part of a broader coping strategy, but it does not prioritize understanding the immediate experience and potential urgency of the hallucinations.