During the initial assessment interview the client becomes anxious and evasive when the nurse asks
her if she has ever heard voices when no one else was around. The client asks, "What do you need to
know that for?" The nurse should say
a. "Please be honest about this," after repeating the question.
b. "Sometimes questions seem highly personal, but we have our reasons for asking
each one.".
c. "What purpose do you think we might have in asking about whether you hear
voices?"
d. "I can see this subject makes you uncomfortable. We can discuss it at another
time.".
ANS: D
The nurse should not try to pry information out of a client who is reluctant to give the information.
The nurse should note the client's reaction to the question and carefully observe for behavioral signs
that the client may be experiencing auditory hallucinations. Option A implies the client has been
dishonest. Option B treats the client in a demeaning fashion. Option C is game playing.
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