The nurse is caring for a client experiencing auditory hallucinations.
Which of the following statements would be most appropriate for the nurse to make to the client?
The nurse is caring for a client experiencing auditory hallucinations.
Which of the following statements would be most appropriate for the nurse to make to the client?
A. “What are you hearing? This sounds quite frightening for you.”
[35%]
B. "What are the voices saying to you? Would you like to go to another room?"
[18%]
C. "What are the voices saying to you? This sounds difficult to experience."
[25%]
D. "This must be tough to hear voices. Can you try to listen to me and the others you can see around you?"
[22%]
Statistics
Subject/Lesson
Subject
Mental Health
Lesson
Mental Health
Client Need
Test Plan
Psychosocial Integrity
Related Topic
Sensory/Perceptual Alterations
Item Type
Item Type
Application
Explanation
Choice A is correct. This is the most appropriate statement for the nurse to make to the client. The nurse should inquire about the content of the hallucination and convey empathy to the client. The nurse should then focus on reality-based "here-and-now" activities such as conversations with statements such as "What you are hearing is part of your illness that we are treating. Try to listen to me and the others you can see around you." This may be difficult if the client has no insight into their illness. However, this is an appropriate strategy to employ.
Choice B is incorrect. The nurse should avoid referring to hallucinations as if they are real. Do not ask, "What are the voices saying to you?". Instead, it would be appropriate to ask, "What are you hearing?" This distinctive difference is therapeutic. This statement does contain empathy, but it is not the most appropriate.
Choice C is incorrect. The nurse should avoid referring to hallucinations as if they are real. Do not ask, "What are the voices saying to you?". It may be appropriate for the client experiencing hallucinations to have a low-stimulation environment and to employ distraction. However, the nurse needs to inquire about the content of the hallucination and convey empathy.
Choice D is incorrect. This statement conveys empathy and focuses on reality. However, the reality statement is a question where clients should be gently instructed to focus on those around them (it should be a statement, not a question). Finally, the response does not inquire about the content of the hallucination, which is key and an early intervention to discern the full complexity of the hallucination.
Additional Info
For the client experiencing hallucinations
✓ Ask about the content of the hallucinations and how the reaction.
✓ Assess for command hallucinations and if the hallucinations are causing fear or distress.
✓ Avoid referring to hallucinations as if they are real. Do not ask, “What are the voices saying to you?” Ask, “What are you hearing?”
✓ Be alert to signs of anxiety, which may indicate that hallucinations are intensifying or that they are of a command type.
✓ Do not negate the client's experience; offer your perceptions and convey empathy. “I don’t hear angry voices that you hear, but that must be very frightening for you.”
✓ Focus on reality-based “here-and-now” activities such as conversations or simple projects. Tell the client, “The things you are hearing are part of your illness, and it cannot hurt you. Try to listen to me and the others you can see around you."
