Question

The health care provider documents in a client's medical record the statement "bizarre gesturing, decline in hygiene, and command hallucinations." Which action is most important for the nurse to take when caring for this client?

1. Note the quality and duration of the gestures.
2. Offer the client a fresh change of clothing.
3. Ask the client what the voices are saying.
4. Administer antipsychotic medication.

Answer 1

The correct answer would be - option 3.

Step-by-step explanation:

The client is experiencing a psychotic problem characterized by the weird gestures, bad hygiene and hallucination about commands or the voices. The nurse should work on the various aspects however the safety should be most important and priority.

If the bizarre gesture is obvious there is finding new symptoms are meaningless by noting the quality and time of gestures. Hygiene is essential but safety should be priority so asking about the voice commands and analyzing risk is most important.

Thus, the correct answer is - option 3.