When Sam pauses and murmurs to himself during reassessment, what is the best nurse response?

When Sam pauses and murmurs to himself during reassessment, what is the best nurse response?

• A. What are you thinking right now?
• B. Tell me about how you're feeling.
• C. Are you hearing any voices?
• D. I notice that you talk to yourself.

Answer: (C)

Directly assessing for hallucinations by asking about voices is the most informative first step when a patient with schizophrenia murmurs or talks to themselves. By asking, “Are you hearing any voices?” you directly probe the symptom, which helps determine whether the patient is experiencing an auditory hallucination and how severe it might be. This approach invites the patient to reveal their internal experiences in a nonjudgmental way and informs next steps for safety, monitoring, and treatment. The other options are less effective for uncovering the actual symptom. Asking what the patient is thinking right now is broad and may miss whether the murmuring is due to voices. Asking about feelings is also broad and doesn’t specifically identify hallucinations. Commenting on the behavior—“I notice that you talk to yourself”—can feel judgmental or dismissive and may shut down honest communication about what the patient is experiencing.

Directly assessing for hallucinations by asking about voices is the most informative first step when a patient with schizophrenia murmurs or talks to themselves. By asking, “Are you hearing any voices?” you directly probe the symptom, which helps determine whether the patient is experiencing an auditory hallucination and how severe it might be. This approach invites the patient to reveal their internal experiences in a nonjudgmental way and informs next steps for safety, monitoring, and treatment.

The other options are less effective for uncovering the actual symptom. Asking what the patient is thinking right now is broad and may miss whether the murmuring is due to voices. Asking about feelings is also broad and doesn’t specifically identify hallucinations. Commenting on the behavior—“I notice that you talk to yourself”—can feel judgmental or dismissive and may shut down honest communication about what the patient is experiencing.