Question

an older female client reports to the nurse that recently she has been hearing voices. which question should the nurse ask this client first?

do you have problems with hallucinations?
are you ever alone when you hear the voices?
has anyone in your family had hearing problems?
do you see things that others cannot see?

Explanation:

Analyze the clinical scenario and client presentation

An older female client reports hearing voices, which is a new-onset sensory-perceptual alteration (auditory hallucination). In an older adult, new-onset hallucinations require a thorough assessment to differentiate between psychiatric conditions and underlying physiological or environmental causes (such as sensory deprivation, social isolation, or physical illness).

Evaluate the assessment options

• "Do you have problems with hallucinations?" uses clinical jargon that may confuse or alienate the client.
• "Are you ever alone when you hear the voices?" directly assesses the context of the hallucinations, helping to determine if social isolation or sensory deprivation (common in older adults when alone) is contributing to the experience.
• "Has anyone in your family had hearing problems?" focuses on physical hearing loss, which is less relevant to the immediate assessment of hearing distinct "voices."
• "Do you see things that others cannot see?" assesses for visual hallucinations, which does not address the immediate complaint of auditory hallucinations.

Determine the priority nursing action

Assessing the environmental context (whether the client is alone) is the most appropriate first step to identify potential contributing factors like sensory deprivation or isolation in an older adult experiencing new auditory hallucinations.

Answer:

• Do you have problems with hallucinations?
• Are you ever alone when you hear the voices? (Correct answer)
• Has anyone in your family had hearing problems?
• Do you see things that others cannot see?