AIIMS Delhi NO- 2019
Mental Health Nursing
Hard
A psychiatric patient states, “I hear voices telling me to harm myself.” What should be the nurse’s priority response?
Appeared in: AIIMS Delhi NO- 2019
Explanation
- The patient's statement describes command auditory hallucinations, which are considered a psychiatric emergency due to the high risk of self-harm or violence.
- The fundamental principle of nursing care is to ensure patient safety above all other interventions. This aligns with Maslow's Hierarchy of Needs, where safety is a foundational requirement.
- In situations of imminent danger, immediate protective action must be taken before proceeding with further assessments, such as exploring the content of the hallucinations.
- The nurse has a legal and ethical duty to protect the patient from preventable harm.
Why Other Options Were Wrong
- Option A: Ignoring a direct statement about self-harm is considered professional negligence and places the patient's life in jeopardy.
- Option B: While assessing the nature of the voices is a crucial part of the overall care plan, it is not the immediate priority. Safety must be established first before further assessment can be safely conducted.
- Option D: Changing the topic is a non-therapeutic communication technique that dismisses the patient's experience and ignores a critical, life-threatening risk.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Prioritizing nursing interventions for a patient with command hallucinations and risk of self-harm to guide bedside assessment, documentation, and the next nursing action.
- A nurse's primary responsibility in any setting is to maintain patient safety. Failure to act on a stated intent of self-harm can have severe legal and ethical consequences, including charges of negligence.
- This scenario highlights the importance of recognizing psychiatric emergencies. Command hallucinations directing self-harm are as critical as a physiological emergency like a heart attack.
- What if the patient had said, 'I hear voices whispering, but I can't make out what they say'? In that case, the immediate priority would shift. The nurse would first ask the patient to describe the voices (Option B) to assess for any potential threat, as the risk is not yet established as imminent.
How to Approach the Question
- First, analyze the question's stem to identify the core problem. The patient is 'hearing voices' (hallucinations) with a command to 'harm myself' (suicidal intent).
- Recognize that this is a priority-based question, indicated by the phrase 'priority response'.
- Apply the fundamental nursing principle of 'Safety First'. In any situation, interventions that ensure the patient's physical safety take precedence over all others (e.g., assessment, comfort, communication).
- Evaluate each option against the 'Safety First' principle.
- Option A (Ignore) and D (Change topic) clearly violate safety. Option B (Ask) is an assessment, which is secondary to taking protective action.
- Option C (Immediately ensure patient safety) is the only response that directly addresses the immediate, life-threatening risk. Therefore, it is the correct priority action.
Concept Tested & Keywords
- Concept Tested: Prioritizing nursing interventions for a patient with command hallucinations and risk of self-harm.
- Stem keywords: psychiatric patient, hear voices, harm myself, priority response
- Lead-in keywords: priority
- Clinical cues: Patient statement: 'I hear voices telling me to harm myself.' - This is a direct report of command hallucinations with intent for self-harm, indicating an immediate and severe safety risk.
- Negative lead-in flag: false
Question ID
Q6TCkIjnGWAaK_hsszHVOV
Reference Book
E6 Robert Boland, Marcia L. Verduin - Kaplan and Sadock's Comprehensive Text of Psychiatry-Wolters Kluwer Health (2024) (pp 1-16525 of 16525) pp. 3252-3254, 3819-3821
E6 Guide to Mental Health & PSYCHIATRIC NURSING R Sreevani— Part 1 (pp 26-289 of 579) p. 199-201
Practise the full AIIMS Delhi NO- 2019
Attempt every question from this paper in a timed mock, then review the full solution for each one.
More Psychiatric Emergencies Questions
- Priority action of patient agitation management?
- A patient has tried to commit suicide with drug overdose. Which of the situation depicts that the patient has high risk of suicide?
- Patient is taking haloperidol and at home Patient is not able to sit quietly, during the clinic visit Patient has the urge to walk. What is suffering…
- A client is admitted to the emergency room with symptoms of delirium tremens. After admitting the client to a private room, the priority nursing inte…
- A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental…
- Which of the following would be a priority nursing intervention for a patient who has suicidal behaviour?
- Which of the following is the most lethal method of Suicide?
- During ward rounds, you find that a 24-year-old patient with mania is very abusive and aggressive; there is imminent danger of his becoming physicall…
- A patient says to a nurse, "Everyone would be better off if I wasn't alive." Which nursing diagnosis would be made based on this statement?
- A patient receiving haloperidol for schizophrenia reports an inner feeling of motor restlessness, stating, "I can't stop moving my legs, I feel like…
More AIIMS Delhi NO- 2019 Questions
- A nurse is preparing to give bath to admitted patient with perineal problem. Which of the following will help the patient?
- In the absence of nurse from floor, patient falls from bed. This type of injury belongs to:
- Patient's Medical record with all essential information is responsibility of:
- Post-partum women having bleeding within 24 hrs after delivery is called:
- In which condition, distal pulse is preferred rather than apical pulse?
- A pre-eclampsia woman's baby is lying with her mother. Neonate is born in 37 weeks. After 57 hours, when nurse is monitoring vital signs of baby, tem…
- A woman with 3rd day postpartum has complaint of engorgement in both breasts. What is cut off temperature for fever in postpartum women?
- Universal blood donor?
- WHO hand wash time with soap?
- Why it is necessary to remove dark coloured nail paint before surgery?