Exhibits

A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Rationale:

A. Respiratory therapist: A respiratory therapist is essential in arranging home oxygen by evaluating the client’s respiratory needs, determining appropriate oxygen flow rates, and ensuring proper use of equipment. They also provide education on safety and maintenance, which is critical for clients newly diagnosed with COPD who must manage oxygen therapy at home.

B. Physical therapist: A physical therapist focuses on mobility and strength training, which can benefit clients with COPD but is not directly responsible for arranging or coordinating home oxygen therapy. Their role becomes more relevant after respiratory support is established and the client begins working on endurance and safe activity levels.

C. Social worker: A social worker assists with social support, financial resources, and coping needs but is not typically involved in arranging clinical respiratory equipment. Their involvement may be helpful later if the client requires community services, but they are not the primary referral for initiating oxygen therapy.

D. Case manager: A case manager plays a key role in long-term discharge planning and may eventually coordinate services, but the immediate need for oxygen setup requires a respiratory therapist’s specialized assessment. Once the respiratory plan is initiated, the case manager can support broader continuity of care needs.

Rationale:

A. Initiate one-to-one observation for the client: One‑to‑one observation is essential for safety when a client expresses risk for self‑harm, but the nurse must first assess the content of the hallucinations to determine the immediacy and severity of the risk. Understanding what the voices are saying guides the urgency of interventions and the level of monitoring required.

B. Turn on soft music to distract the client from hearing voices: Distraction techniques can help clients manage hallucinations, but they are not appropriate as an initial action when the client is reporting commands related to self‑harm. The priority is to gather critical assessment data before attempting coping strategies that may not address imminent danger.

C. Ask the client what they are hearing: Assessing the content, tone, and intent of the hallucinations is the first priority because command hallucinations can pose significant danger. Asking directly helps the nurse determine whether the client has an immediate plan or intent to act, which guides safety precautions and necessary interventions.

D. Refer to the hallucination as if it were real: Reinforcing hallucinations can worsen the client’s disorientation and increase distress. The nurse should maintain therapeutic boundaries by acknowledging the client’s experience without validating the hallucination, while also performing an immediate assessment of the risk of self‑harm.