A nurse is assessing a 35-year-old client who was recently admitted to the psychiatric unit with a diagnosis of schizophrenia. Which assessment finding would be most indicative of a positive symptom of schizophrenia?

Auditory hallucinations (hearing voices) are a classic positive symptom of schizophrenia, indicating an excess of normal function. Other options (flat affect, poor hygiene, monotone speech) are negative symptoms representing a loss of normal function.

Understanding Positive vs. Negative Symptoms in Schizophrenia
Schizophrenia symptoms are broadly categorized into positive and negative symptom clusters. Positive symptoms reflect an excess or distortion of normal functions—phenomena that are “added” to the person’s experience, such as hallucinations, delusions, disorganized speech, and grossly disorganized or catatonic behavior. In contrast, negative symptoms represent a diminution or loss of normal functions, including flat affect, alogia (poverty of speech), avolition, anhedonia, and social withdrawal.

Analysis of the Assessment Findings
The correct answer is the client’s report of hearing voices stating that their food is poisoned. This is a classic example of an auditory hallucination, which is a hallmark positive symptom. The content of the hallucination—a persecutory belief about being poisoned—also illustrates how hallucinations frequently intertwine with paranoid delusions. According to the provided evidence, auditory hallucinations are a core, disabling symptom of schizophrenia, affecting an estimated 50-70% of patients ^[1]. These phenomena are often persistent and distressing, and are frequently poorly controlled by antipsychotic medication alone, highlighting their clinical significance as a primary target for both pharmacologic and non-pharmacologic interventions ^[2][3].

The other options describe negative symptoms:
- Flat affect (option 1) and a monotone voice with limited verbal responses (option 3, which is a form of alogia) both represent a decrease in emotional expression and speech production.
- Poor personal hygiene and a disheveled appearance (option 2) often stem from avolition, a negative symptom involving a lack of motivation to initiate and perform purposeful activities.

Clinical Significance and Nursing Implications
For the NCLEX-RN, distinguishing between these symptom clusters is fundamental for assessment, planning care, and evaluating treatment outcomes. A client reporting command or persecutory auditory hallucinations requires immediate safety evaluation and implementation of therapeutic communication techniques. The evidence base reinforces that managing these hallucinations is complex, with multimodal approaches such as mindfulness-based therapy ^[1] and repetitive transcranial magnetic stimulation ^[3] being investigated to address symptoms that are resistant to medication alone. When a nurse identifies a positive symptom like an auditory hallucination, the priority is to acknowledge the client’s experience without reinforcing the delusion, assess for command content that may indicate a risk of harm to self or others, and provide a safe, low-stimulation environment.