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NCLEX · Therapeutic Communication

A client with schizophrenia says: 'The voices are telling me to hurt myself.' What is the nurse's FIRST priority action?

Correct answer

Complete a safety assessment and ensure the client is in a safe environment — assess whether the voices have given a specific plan, whether the client intends to act, and implement safety precautions immediately

  1. A Continue the therapeutic conversation without interrupting
  2. B Complete a safety assessment and ensure the client is in a safe environment — assess whether the voices have given a specific plan, whether the client intends to act, and implement safety precautions immediately
  3. C Document it and notify the RN at the end of shift
  4. D Ask the client to ignore the voices

Why this is the answer

COMMAND HALLUCINATIONS (voices commanding self-harm or harm to others) are a psychiatric emergency. PRIORITY: SAFETY. IMMEDIATE ACTIONS: Stay with the client; do not leave them alone; assess lethality — does the client intend to obey the voices? Do they have a means? Remove or secure potentially lethal items within reach; notify the RN immediately; implement 1:1 or continuous observation per facility policy; PRN medication may be ordered for acute agitation; COMMUNICATION: Remain calm, non-threatening; acknowledge that the voices feel real to the client without validating the command content ('I know the voices feel very real to you; I'm concerned about your safety right now'); do not argue about whether voices are real; focus on safety, not on the content of hallucinations; DOCUMENTATION: Accurate, timely documentation of the client's statement and the nursing response.
Source: NCLEX-PN PS — Mental Health Safety, Command Hallucinations

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