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) Encourage the client to ignore the voices
B) Administer an antipsychotic medication
C) Request the client to describe the voices
D) Isolate the client for safety

Answer 1

The correct action for a nurse when a client reports hearing voices is to engage in conversation, requesting the client to describe the voices and their experience. It's important to document and report the information to the healthcare team for further assessment and to form an appropriate care plan.

Step-by-step explanation:

When a client on a mental health unit reports experiencing auditory hallucinations such as voices telling them what to do, the appropriate nursing action would be to engage the client in a conversation about these voices. Encouraging the client to describe the voices, what they are saying, how often they hear them, and how the voices make them feel is a therapeutic approach and can provide valuable information for their care plan. It also helps to establish a trustful nurse-client relationship. Isolating the client or encouraging them to ignore the voices is not a therapeutic approach and can increase feelings of alienation or distress. Administering medication without a thorough assessment and an order from a healthcare provider is not within the scope of nursing practice.

Moreover, such symptoms can indicate a psychiatric condition that may require a specific treatment plan which might include psychosocial interventions and possibly pharmacological therapies. Therefore, the nurse should listen attentively, document the client's experience accurately, and report these findings to the psychiatric healthcare team for a comprehensive assessment.