# Situation: A barangay health worker (BHW) asks the public health nurse of the Rural Health Unit (RHU) to visit a family in a farming barangay. For 4 months, the son, 22, has stayed in his room most of the day, talks and laughs to himself, and has stopped working. He lives with his widowed mother, 58, and his sister, 19. He has never been seen by a health worker. At a later visit, the mother is with the nurse in the son's room, and his sister is cooking in the kitchen a few steps away. The son, sitting on his mattress, says calmly that the voices are getting louder and order him to hurt his sister, and that he keeps a large knife under that mattress. He is not holding the knife. Which should the nurse do FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627147  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: A barangay health worker (BHW) asks the public health nurse of the Rural Health Unit (RHU) to visit a family in a farming barangay. For 4 months, the son, 22, has stayed in his room most of the day, talks and laughs to himself, and has stopped working. He lives with his widowed mother, 58, and his sister, 19. He has never been seen by a health worker.

At a later visit, the mother is with the nurse in the son's room, and his sister is cooking in the kitchen a few steps away. The son, sitting on his mattress, says calmly that the voices are getting louder and order him to hurt his sister, and that he keeps a large knife under that mattress. He is not holding the knife. Which should the nurse do FIRST?

## 보기

1. Stay with him and keep him talking calmly in his room
2. Ask him calmly to give her the knife under his mattress
3. Ask the mother to take the sister out of the house now **✔ 정답**
4. Call the RHU physician to arrange emergency evaluation today

**정답: 3**

## 해설

Command hallucinations to hurt a named person, with a weapon within reach, are a safety emergency, and all four actions belong in the response. The person in immediate danger is the sister, who is a few steps away, and moving her out of the house removes that danger at once without confronting him. Retrieving the knife from under the mattress he is sitting on risks a confrontation and is done with help, the call for emergency evaluation follows at once, and the nurse stays and keeps talking calmly while help comes.

## 심화 해설

Immediate Safety Priority

The first nursing action must address the person at greatest immediate physical risk. In this scenario, the son is experiencing command hallucinations—auditory hallucinations that direct him to harm a specific, identified person (his sister). He also has access to a weapon: a large knife under the mattress on which he is sitting. The sister is only a few steps away in the kitchen. Because the threat is directed at a named individual who is physically nearby, the highest-priority intervention is to remove that potential victim from the environment without delay.

Command hallucinations to harm a named person, combined with a weapon within reach, constitute a psychiatric safety emergency requiring immediate separation of the potential victim from the patient. The nurse should ask the mother to take the sister out of the house now. This action does not require confronting the son, does not involve reaching for the weapon, and immediately reduces the risk of harm to the sister.

Watch out! Asking the son to hand over the knife may seem logical, but it risks escalating the situation. The son is sitting on the mattress where the knife is hidden, and any attempt to retrieve it could be perceived as a threat, triggering agitation or violence. Weapon removal is done with assistance and after the immediate victim is safe.

Why Not the Other Options First?

| Option | Why It Is Not the First Action |
| --- | --- |
| 1. Stay and keep him talking calmly | Maintaining verbal engagement is important, but it does not remove the sister from immediate danger. The nurse can continue talking after the sister is out of the house. |
| 2. Ask him to give the knife | Directly requesting the weapon while he is sitting on it risks confrontation and escalation. This is done with help and after the victim is safe. |
| 4. Call the RHU physician for emergency evaluation | Emergency evaluation is necessary, but it takes time to arrange. The sister's safety cannot wait for a phone call or transport arrangement. |

Clinical Reasoning and Risk Assessment

Structured professional judgment tools, such as V-RISK-10, are used in psychiatric settings to screen for violence risk. Research on multidisciplinary use of V-RISK-10 in psychosis wards highlights that risk assessment is most effective when it links directly to risk management—meaning the assessment must lead to concrete protective actions [1]. In this community setting, the protective action that can be implemented fastest is removing the sister from the home.

The presence of a specific victim named in the hallucination is a particularly concerning feature. Community-based studies of psychiatric emergencies among patients with severe mental disorders show that emergency interventions are often triggered by acute symptom exacerbations that create immediate danger to self or others . The son's calm demeanor does not reduce risk; individuals experiencing command hallucinations may comply with the commands without visible agitation.

The nurse's first responsibility is to protect the identified potential victim, not to negotiate with the patient or retrieve the weapon. Once the sister is out of the house, the nurse can remain with the son, maintain calm communication, and arrange for emergency psychiatric evaluation and safe weapon removal with additional help.

Applying the Nursing Process

In the assessment phase, the nurse identifies that the son has command hallucinations to harm his sister, access to a weapon, and the sister is nearby. The nursing diagnosis is Risk for Violence: Other-Directed related to command hallucinations and weapon access. The planning phase prioritizes immediate victim safety. The implementation begins with removing the sister from the environment, followed by maintaining a calm presence, arranging emergency evaluation, and coordinating safe weapon removal with assistance. Evaluation includes confirming the sister is safe, the son remains calm, and emergency services are en route.

Key point! In any situation involving a threat to a specific person, the first nursing action is always to protect the potential victim. Only after the victim is safe does the nurse address the patient's immediate psychiatric needs and arrange for further evaluation and intervention.References (research sources)

- [1]Better safe than sorry - a qualitative study of multidisciplinary use of the V-RISK-10 in assessing patients with psychosis.Research articleSeierstad A, Bruu BK, Schjøtt-Pedersen O, Løvgren A, Lockertsen Ø. (2025) · DOI: 10.3389/fpsyt.2025.1561082

## 임상 시나리오

Command Hallucination with WeaponImmediate safety action in a home visit
When a patient has command hallucinations to harm a named person and a weapon within reach, the first action is to remove the potential victim from the environment. This reduces immediate danger without confronting the patient.

Weapon retrieval is deferred until the victim is safe and assistance is available. Emergency evaluation and verbal de-escalation follow immediately after separation.

CautionDo not reach for a weapon under a patient who is sitting on it; this can be perceived as a threat and escalate violence. Keep the patient in view while the victim leaves.

## 핵심 개념

- **Command hallucination** — Auditory hallucination directing a person to perform a specific act, often harm to self or others
- **Safety emergency** — A situation with imminent risk of harm requiring immediate protective action
- **Potential victim** — The named target of a threat who is physically accessible to the patient
- **Weapon access** — Availability of an object capable of causing harm, increasing immediate danger
- **De-escalation** — Verbal and behavioral techniques to reduce agitation without confrontation

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