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 is a classic example of command auditory hallucinations, where voices instruct the person to perform an act.
- When the command is to inflict self-harm, it constitutes a psychiatric emergency, indicating an imminent risk of suicide or self-injury.
- The core principle of nursing prioritizes patient safety above all else (similar to Maslow's Hierarchy of Needs). Immediate action to prevent harm is required before any other intervention.
- Therefore, the nurse must first act to secure the patient's environment and ensure they cannot harm themselves.
Why Other Options Were Wrong
- Option A: Ignoring a direct threat of self-harm is considered professional negligence and places the patient's life in immediate danger.
- Option B: While assessing the content and nature of the hallucinations is a crucial part of the overall nursing process, it is not the immediate priority. Safety must be established first.
- Option D: Changing the topic is a non-therapeutic communication technique that invalidates the patient's experience, dismisses their distress, and fails to address the 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.
- Nurses have a legal and ethical duty to protect patients from foreseeable harm. Failure to act on a stated intent for self-harm can have severe legal and professional consequences.
- This scenario highlights the critical thinking skill of prioritization. In clinical practice, nurses must constantly decide which action is most important. The 'Safety First' rule is a cornerstone of this decision-making process.
- What if the patient's statement was, "The voices are telling me I'm worthless"? In this case, while still serious, the immediate risk is less acute than a direct command to self-harm. The priority would shift from immediate physical intervention to therapeutic engagement and assessment (Option B) to explore the suicidal ideation that might be underlying the feeling of worthlessness, while still maintaining a high level of vigilance.
How to Approach the Question
- First, identify the question type. This is a priority-based clinical scenario question, asking for the most important nursing action.
- Analyze the patient's statement: "I hear voices telling me to harm myself." Break this down into two key parts: 'hearing voices' (hallucination) and 'telling me to harm myself' (command for self-harm).
- Recognize that any mention of self-harm or suicide is a red flag that signals an immediate safety risk.
- Apply the fundamental nursing principle of 'Safety First'. This is based on frameworks like Maslow's Hierarchy of Needs, where physiological and safety needs must be met before any others.
- Evaluate the options based on this principle. Which option directly addresses the immediate threat to the patient's life?
- Eliminate options that are passive (Ignore), non-therapeutic (Change the topic), or secondary in priority (Ask to describe) compared to the option that ensures physical safety.
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.
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