Question

a male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. during the admission procedure, the client looks up and states,
o, its not my fault. you cant blame me. i didnt kill him, you did.\ which action is best for the nurse to take?

reassure the client by telling him that his fear of the admission procedure is to be expected.
tell the client that no one is accusing him of murder and remind him that the hospital is a safe place.
assess the content of the hallucinations by asking the client what he is hearing.
ignore the behavior and make no response at all to his delusional statements.

Explanation:

Analyze client behavior and statements

The client is looking up and responding to an unseen stimulus ("No, it's not my fault... I didn't kill him, you did"), which strongly indicates he is experiencing auditory hallucinations, specifically accusatory or commanding voices.

Evaluate nursing interventions for active hallucinations

When a client with paranoid schizophrenia appears to be responding to internal stimuli, the nurse's immediate priority is to assess the content of the hallucinations to ensure safety (e.g., determining if they are command hallucinations instructing harm).

Compare the given options

• Option 1: Reassuring about admission fear does not address the immediate hallucinatory experience.
• Option 2: Telling him no one is accusing him of murder addresses a delusion rather than assessing the active hallucination, and may argue with his reality.
• Option 3: Assessing the content of the hallucinations by asking what he is hearing directly addresses safety and gathers essential clinical data.
• Option 4: Ignoring the behavior is unsafe, as the voices could be commanding him to act violently.

Answer:

• Reassure the client by telling him that his fear of the admission procedure is to be expected.
• Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place.
• Assess the content of the hallucinations by asking the client what he is hearing. (Correct answer)
• Ignore the behavior and make no response at all to his delusional statements.