During an assessment, a patient reports hearing voices in the head. What should be the priority for the nurse?
1. Determine if the voices are fantasy hallucinations.
2. Determine if the voices are command hallucinations.
3. Determine if the patient has a disturbance in orientation.
4. Determine if the patient has a disturbance in thought process.
2. Determine if the voices are command hallucinations.
Explanation:
The patient is experiencing auditory hallucinations. The priority is to determine if the hallucinations are command hallucinations, which may place the patient in danger of harming self or others. The priority is not to determine if the hallucinations are fantasy oriented. While the nurse will assess if the patient has a disturbance in thought process and orientation, these are not the most important things for the nurse to assess regarding the patient's symptoms.
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