What is the priority response by the nurse to a client hearing a voice saying harmful things?

When a client reports hearing a voice that says harmful things, the priority response is to explore the content of what they are experiencing. Asking, "What did the voice tell you?" serves several important purposes. It allows the nurse to assess the severity and nature of the hallucination, which is crucial for determining the level of risk the client may face. Understanding the specifics can help the clinician identify any potential for self-harm or harm to others, enabling an appropriate response and intervention.

Moreover, this question demonstrates an empathetic approach, validating the client's experience and encouraging them to share their thoughts and feelings. This can help establish trust between the client and nurse, which is vital for effective therapeutic communication.

In comparison, the other options are less effective in addressing the client's immediate psychological needs. Suggesting that they may have overheard staff can dismiss the reality of their experience and may lead to feelings of isolation or misunderstanding. Offering medication for anxiety may be a part of the overall treatment plan but does not address the acute nature of the client's concern or provide understanding of their current mental state. Assuring them that they are safe may be comforting, but it does not engage with the disturbing content of the hallucination, which is essential for safety assessment and therapeutic intervention.