Schizophrenia

A nurse is caring for a client with schizoaffective disorder who has been experiencing auditory hallucinations commanding them to harm others. Which nursing intervention should be the nurse's immediate priority?

The client reports hearing voices telling them to "hurt the people who are trying to poison me" and appears agitated and suspicious of staff members.

1 Administer prescribed antipsychotic medication as ordered
2 Engage the client in reality orientation techniques
3 Encourage the client to discuss the content of the hallucinations
4 Ensure environmental safety and remove potential weapons ✓ 정답

해설

When a client with schizophrenia experiences command hallucinations involving harm to others, immediate priority is safety. Environmental safety measures, such as removing potential weapons, protect both the client and others before other interventions like medication or reality orientation.

같은 주제 다음 문제A nurse is assessing a 35-year-old client who was recently admitted to the psychiatric uni…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX), 이거 하나면 됩니다69,000원

Priority Nursing Intervention for Command Hallucinations with Harm Intent

The nurse's immediate priority is to ensure environmental safety and remove potential weapons. This intervention directly addresses the principle of maintaining a safe milieu, which is the foundational step before any other therapeutic interaction can occur when a client poses an imminent risk of violence.

The client's presentation—command auditory hallucinations with a specific directive to harm others, coupled with agitation and paranoia—constitutes a psychiatric emergency. In this context, the safety of the client, other patients, and staff is the paramount concern. The clinical reasoning follows a hierarchy of risk management: first, secure the physical environment to prevent immediate harm. The research underscores that psychiatric emergency settings carry a significant risk for physical assault, which can be precipitated by acute psychotic symptoms ^[1]. By proactively removing objects that could be used as weapons, the nurse eliminates an environmental driver that could escalate a verbal threat into a physical act of violence. This action is a critical component of de-escalation and aligns with the broader goal of minimizing formal coercion, such as physical restraint, by managing contextual features that contribute to behavioral emergencies ^[2].

The other options, while important in the overall plan of care, are not the immediate priority. Administering prescribed antipsychotic medication (Option 1) is essential for symptom stabilization, but its onset of action is not instantaneous; it does not address the immediate, seconds-to-minutes risk of harm. Engaging in reality orientation techniques (Option 2) is contraindicated when a client is acutely agitated and psychotic, as directly challenging their fixed false beliefs can heighten anxiety and aggression. Encouraging the client to discuss the content of the hallucinations (Option 3) is a later-stage intervention for building insight and coping strategies, but in an acute crisis, focusing on the commands can reinforce their perceived power and increase the client's distress and potential for acting on them. The immediate clinical task is to control the environment to prevent a behavioral emergency, thereby reducing the likelihood that more restrictive interventions will become necessary ^[2].

References (research sources)

[1]
Physical Assault in the Psychiatry Emergency Room.Research articleLawrence RE, Rolin SA, Looney DV, Birt AR, Stevenson EM, Dragatsi D, Appelbaum PS, Dixon LB. (2020) · DOI: 10.29158/jaapl.200022-20
[2]
Functional, Contextual, and Interventional Drivers of Formal Coercion in Acute Mental Health Units: A Feature Analysis.Research articleDaguman EI, Yoxall J, Lakeman R, Hutchinson M. (2026) · DOI: 10.1111/inm.70240

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A nurse is caring for a client with schizoaffective disorder who has been experiencing auditory hallucinations commanding them to harm others. Which nursing intervention should be the nurse's immediate priority?

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