A new nurse is preparing to assess a patient who is experiencing auditory hallucinations. Which statement by the nurse requires follow-up?
I find if I pretend the hallucinations are real, it reduces my patient’s anxiety.
I can assess for hallucinations by asking, “Are you hearing voices other than mine?”
I can ask if the patient has found ways to cope with the hallucinations.
I need to also assess if the patient is having command hallucinations.
The Correct Answer is A
A: This statement requires follow-up because pretending that hallucinations are real can reinforce the patient’s delusions and is not a therapeutic approach. It is important to acknowledge the patient’s experience without validating the hallucinations as real.
B: This statement is appropriate as it directly assesses the presence of hallucinations in a clear and straightforward manner.
C: This statement is also appropriate as it helps to understand how the patient is managing their symptoms and can guide further interventions.
D: Assessing for command hallucinations is crucial because these types of hallucinations can pose a risk to the patient or others if they involve harmful commands.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Paranoid personality disorder is characterized by pervasive distrust and suspicion of others, which is not reflected in the client’s statement.
B: Antisocial personality disorder involves a disregard for the rights of others and a lack of remorse, which is not indicated in the client’s statement.
C: Schizoid personality disorder is characterized by a lack of interest in social relationships and emotional coldness, which does not align with the client’s statement.
D: Borderline personality disorder is characterized by intense and unstable relationships, often involving idealization and devaluation of others. The client’s statement reflects this pattern by idealizing one nurse and devaluing another.
Correct Answer is B
Explanation
A: Limiting communication to only the mother is not recommended as it can hinder the child’s social development and interactions with other family members.
B: Teaching parents to provide structure, rewards, and consistency in following rules is an effective intervention. Children with autism spectrum disorder benefit from predictable routines and clear expectations, which help reduce anxiety and improve behavior.
C: While some children with autism may find eye contact challenging, minimizing eye contact is not a universal recommendation. It is more important to understand the individual child’s needs and preferences.
D: Speaking in a loud tone of voice is not appropriate as it can be overwhelming and distressing for the child. Clear, calm, and consistent communication is more effective.
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