A newly admitted patient tells the nurse, "The voices are bothering me." The nurse should first
a. ignore the patient's reference to voices.
b. distract the patient from the hallucinations.
c. tell the patient that the voices do not exist.
d. seek a description of the voices and identify themes.
D
Early assessment of hallucinations is based on the content of the messages. Content often reveals the dynamics of the patient's symptoms and typically revolves around a theme such as powerlessness, hate, guilt, or loneliness. Ignoring the reference is nontherapeutic and thwarts assessment. Distraction is a possible strategy after the nurse understands the content of the hallucinations. Saying that the voices do not exist negates the patient's experience. Saying you do not hear them is preferable.
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