# A nurse is caring for an adult client newly admitted to the inpatient psychiatric unit who is experiencing active auditory hallucinations related to schizophrenia. The client states, "The voices are telling me that the nurses here want to harm me." Which therapeutic responses should the nurse use? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=366332&lang=en  
> language: en  
> subject: Crisis Intervention  
> category: PSI

## Question

A nurse is caring for an adult client newly admitted to the inpatient psychiatric unit who is experiencing active auditory hallucinations related to schizophrenia. The client states, "The voices are telling me that the nurses here want to harm me." Which therapeutic responses should the nurse use? Select all that apply.

1

Directly tell the client that the voices are not real and that no one wants to harm the client, since clearly challenging hallucinations will help the client reach reality

2

Encourage the client to engage with the voices conversationally to better understand their content and meaning

3

Maintain a calm, low-stimulus environment and offer the client a coping strategy such as a focused activity, music with headphones, or a brief walk with staff

4

Use group therapy as the primary intervention immediately on admission, before pharmacotherapy or a one-on-one safety assessment

5

Acknowledge the client's distress without confirming or arguing the reality of the voices, for example, "I can see that this is frightening for you. I do not hear the voices, but I understand they feel very real to you"

6

Assess for command hallucinations directing harm to self or others by asking, "What are the voices telling you to do?"

## Explanation

Acknowledge the client's distress and present reality without arguing with or reinforcing the hallucination (Choice 5). Ask what the voices are saying and assess specifically for commands to harm self or others because these findings change the immediate safety plan (Choice 6). Reduce stimulation and offer a focused coping activity or supportive staff presence (Choice 3). Directly insisting that the voices are not real can damage trust (Choice 1). Encouraging the client to converse with the voices reinforces the hallucination (Choice 2). Group therapy is not the first intervention during acute psychosis before an individual safety assessment and stabilization (Choice 4).

## In-depth explanation

Therapeutic Approach to Active Hallucinations
1. Acknowledge feelings, present reality without arguing
2. Screen for command hallucinations — "What are the voices telling you to do?" → if commands to harm, escalate to 1:1
3. Reduce stimuli — quiet area, calm voice, fewer staff in room
4. Offer coping — focused activity, headphones with music, walking, breathing exercises
5. Pharmacotherapy — antipsychotics (risperidone, olanzapine, haloperidol) per provider order

Therapeutic Communication Examples
- "I do not hear the voices, but I can see they upset you."
- "What do the voices say?"
- "Let's try the music with your headphones for a while."
Avoid: arguing ("they are not real"), agreeing ("I hear them too"), or detailed exploration of content beyond safety screening.

Memory Tip
"A · S · S · I · S · T": Acknowledge, Screen commands, Stimuli reduce, Interact present-focused, Support coping, Treat with meds.

Caution
Group therapy and confrontational reality testing are contraindicated during acute psychosis. Re-introduce after stabilization.

## Clinical scenario

Scenario
Adult, acute schizophrenia exacerbation, just admitted involuntarily. Auditory hallucinations active; affect frightened; suspicious of staff. No prior violence, no current weapons.

Initial Assessment
1. Safety screen: command hallucinations to harm self/others?
2. Insight: aware these are voices, or believes them as external reality?
3. Trigger: medication non-adherence, substance use, recent stressor?
4. Suicide/violence: standard inpatient assessment

Plan of Care
- Quiet, low-stimulus room near nursing station
- 15-min checks, escalate to 1:1 if commands to harm
- Antipsychotic per order (e.g., risperidone or olanzapine)
- Therapeutic relationship: short, frequent, calm interactions
- Coping kit: noise-canceling headphones, music, fidget items, journaling
- Defer group therapy until stable

Family Education
Encourage medication adherence, recognize early warning signs of relapse (sleep disturbance, withdrawal, increased suspicion), avoid arguing with delusions/hallucinations.

## Key concepts

- **Hallucinations** — Sensory perceptions in the absence of an external stimulus. Auditory most common in schizophrenia. Other types: visual (often delirium, substance use), tactile (substance withdrawal), olfactory/gustatory (rule out neurological cause). Always assess for command hallucinations and content suggesting harm to self/others.
- **Therapeutic communication in psychosis** — Acknowledge feelings, present reality calmly without arguing or agreeing with the hallucination, screen for safety, use simple direct language, allow time for response, avoid sarcasm and abstract phrasing. Maintain calm presence and consistent boundaries.
- **Command hallucinations** — Auditory hallucinations that direct the client to perform an action, often violent (harm self or others). Critical safety assessment: ask directly what the voices say, who or what they target, whether the client feels compelled to obey. Commands to harm warrant 1:1 observation, removal of means, immediate provider notification.

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