hard · NCLEX-RN Psychosocial Integrity
The RN is caring for a client with schizophrenia who is hearing 'voices' (command hallucinations) telling them to hurt a staff member. Which interventions are the highest priority? Select all that apply.
- Increase the level of observation and ensure staff safety protocols are followed.
- Instruct the client to 'ignore the voices' and focus on a crossword puzzle.
- Ask the client directly, 'What are the voices telling you to do?'
- Tell the client that their voices are 'just their imagination' and are not real.
- Notify the healthcare provider and the security team of the specific threat.
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