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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is A
Explanation
A: These symptoms are typical of opioid withdrawal. Pain, muscle spasms, diaphoresis (sweating), nausea, and vomiting are common as the body reacts to the absence of the drug.
B: Slurred speech, sedation, hyporeflexia (reduced reflexes), and disorientation are more indicative of opioid intoxication rather than withdrawal.
C: Hypertension and tachycardia can occur during withdrawal, but mental alertness and euphoria are not typical. Euphoria is associated with opioid use, not withdrawal.
D: Paranoid delusions and synesthesia are not typical of opioid withdrawal. Rhinorrhea (runny nose) and lacrimation (tearing) are common, but the other symptoms listed do not align with opioid withdrawal.
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