A nurse is collecting data for a client who has schizophrenia. The client states that he hears voices telling him to do "bad things." The nurse should recognize this finding as which of the following?
Automatic obedience
Gustatory hallucination
Negativism
Command hallucination
The Correct Answer is D
Choice A reason: Automatic obedience refers to a client automatically following instructions without resistance, not hearing voices.
Choice B reason: Gustatory hallucination involves false perceptions of taste, not auditory commands.
Choice C reason: Negativism is resistance to instructions or doing the opposite of what is asked, not hearing voices.
Choice D reason: Command hallucinations are auditory hallucinations where voices instruct the client to perform actions, often harmful. This is a dangerous symptom requiring immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Resting with eyes closed may temporarily relieve blurred vision but does not address the underlying issue of possible lithium toxicity.
Choice B reason: Blurred vision and nausea are signs of lithium toxicity. The nurse should withhold the medication and notify the provider immediately to prevent worsening toxicity.
Choice C reason: Waiting to re-check in 4 hours delays intervention and increases risk of harm.
Choice D reason: Administering the next dose despite symptoms could worsen toxicity and endanger the client.
Correct Answer is A
Explanation
Choice A reason: Encouraging focus on reality-based issues helps redirect the client gently without reinforcing delusions. It maintains therapeutic communication while grounding the client.
Choice B reason: Asking for meaning focuses attention on the delusion, reinforcing it rather than redirecting.
Choice C reason: Persuading the client that thoughts are not true is confrontational and ineffective. Clients with schizophrenia may not accept reality testing when actively delusional.
Choice D reason: Allowing continued delusional talk reinforces psychosis and does not promote reality orientation.
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