RN Comprehensive Predictor 2023 Proctored Exam
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
Explanation & Rationale
A. Asking about medication adherence is important but not the priority when assessing for immediate harm. B. Asking how long the hallucinations have occurred is useful for history-taking but does not assess immediate risk. C. The priority is safety. Asking what the voices are saying helps determine if the hallucinations are command hallucinations, which may instruct the client to harm themselves or others. D. This response acknowledges the client's experience but does not assess for danger.
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