A client reports command hallucinations to die and access to a lethal method. For each nursing response, identify whether it is appropriate now or unsafe.
Matrix
Choose your responses, then check the answer.
Explanation
A command to die combined with a specific plan and access to a lethal method indicates an acute safety emergency. The nurse asks directly about intent, timing, plan, and access; remains with the client according to the immediate safety response; secures the environment and lethal means through facility policy; and notifies the responsible team for urgent assessment and observation orders. A calm statement can acknowledge that the experience is frightening without validating the voice as real. The nurse cannot promise secrecy, argue with the hallucination, shame the client, or leave the client alone while seeking help.
Correct Answer Use direct assessment, continuous safety, means restriction, therapeutic communication, and immediate escalation.
Why It Fits The client describes command hallucinations, suicidal intent cues, a specific plan, and current access to a lethal method.
Clinical Picture The disclosed object creates a modifiable environmental risk while the nurse activates the unit's suicide-safety process.
Memory Link Ask directly, stay, secure means, escalate.
NCLEX Rule Safety overrides a request for secrecy when there is imminent risk of self-harm.
Why the Alternatives Fail Promises of confidentiality, confrontation about whether the voice is real, or leaving to make a call can increase isolation and access to harm.
Sources
1VA/DoD 2024 Suicide Risk Clinical Practice Guideline
Inpatient mental-health unitThe client says, 'A voice keeps telling me to kill myself tonight.' The client reports a specific plan and says a sharp object is hidden in a personal bag. The client appears frightened and asks the nurse not to tell anyone.
Command hallucination — A perceptual experience in which a voice directs the person to perform an action.
Means restriction — Reducing or removing access to objects, medications, or environments that could be used for self-harm.
Suicide safety plan — A collaborative, individualized plan for warning signs, coping, supports, and safer access to help; it is not a no-harm contract.