Question

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor." Which of the following is the priority action for the nurse to take?

A. Use therapeutic communication to discuss the hallucination with the client.
B. Initiate one-to-one observation of the client.
C. Focus the client on reality.
D. Notify the provider of the client's statement.

ATI RN Mental Health Nursing Modules Ch. 14 Notes

Answer 1

The priority action for the nurse is to initiate one-to-one observation of the client, followed by notifying the provider. Therapeutic communication is important but ensuring safety takes precedence.

Step-by-step explanation:

The priority action for the nurse to take in this situation would be to initiate one-to-one observation of the client. This ensures the safety of the client and those around her. Hearing voices to harm oneself or others is a serious symptom of a mental health disorder, and immediate intervention is necessary.

While using therapeutic communication to discuss the hallucinations may be important, ensuring safety takes precedence in this scenario.

It is also important to eventually notify the provider of the client's statement, as they need to be aware of the client's condition and may recommend further interventions or adjustments to the treatment plan.