A client with schizophrenia says, "The voices are telling me to do something bad." Which response is the nurse's priority?
1Tell the client the voices are not real and should be ignored.
2Offer headphones and ask the client to stay alone in the room.
3Change the subject to a pleasant activity.
4Ask what the voices are saying and assess for risk of harm.✓ Correct answer
Explanation
Command hallucinations require immediate safety assessment. The nurse should ask what the voices are saying and assess whether the client may harm self or others. Arguing about reality, isolating the client, or distracting before risk assessment can miss an urgent safety threat.
Clinical Judgment When hallucinations include commands, the first nursing question is about safety and specific content.
Memory Tip Command voice: ask content, assess danger.
KR vs US NCLEX psychiatric safety items reward direct risk assessment, not reassurance alone.
Clinical Practice GuideNIMH describes hallucinations as hearing or seeing things others do not, including voices that may tell a person to do something. Safety assessment is essential when harmful commands are possible.
CautionAsk direct, calm questions about suicidal or violent thoughts when risk cues appear.
Hallucination — A sensory experience, such as hearing voices, that occurs without an external stimulus.
Command Hallucination — A hallucination that directs the person to take an action.
Risk Assessment — Focused questions and observations used to evaluate possible harm to self or others.