A nurse is collecting data from a client who has schizophrenia.
Which of the following client statements indicates that the client is experiencing a command hallucination?

"Can you see these spiders crawling all over me?"

"The aliens are going to abduct me tonight.”.

"Are you planning to kill me?"

"The voices told me to quit eating the food here.”.

Answer and Explanation

The Correct Answer is D

Choice A rationale

The statement "Can you see these spiders crawling all over me?" indicates a visual hallucination, not a command hallucination.

Choice B rationale

The statement "The aliens are going to abduct me tonight.”. reflects a delusional belief, not a command hallucination.

Choice C rationale

The statement "Are you planning to kill me?" suggests paranoia and suspicion, not a command hallucination.

Choice D rationale

The statement "The voices told me to quit eating the food here.”. is indicative of a command hallucination, where the client hears voices instructing them to take specific actions.

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Correct Answer is A

Explanation

Choice A rationale

Limiting the client's need to make decisions helps reduce stress and confusion, which can exacerbate symptoms of delirium. Simplifying choices and providing a structured environment can aid in orientation and reduce cognitive overload.

Choice B rationale

Discouraging visitation from the client's family can increase feelings of isolation and anxiety. Family support can provide comfort and reassurance, which are beneficial for clients with delirium.

Choice C rationale

Keeping the client's room dark at night can disorient them further. Maintaining a well-lit environment helps with orientation and reduces the likelihood of hallucinations or worsening confusion.

Choice D rationale

Providing a high-stimulation environment can increase agitation and confusion. A calm, low-stimulation environment helps minimize stress and can aid in the recovery of clients with delirium.

A. I can encourage my child to think about what they did that allowed this event to happen. B. I anticipate that my child will feel some self-blame. C. I should encourage my child to focus solely on the future. D. I will have to do all I can to monitor my child's relationships.

Correct Answer is D

Explanation

Choice A rationale

Blaming the adolescent for the assault can increase feelings of shame and guilt, exacerbating the trauma and hindering recovery. It's important to provide support without assigning blame.

Choice B rationale

Anticipating self-blame, while acknowledging a common response, doesn't offer the positive support needed for recovery. The focus should be on affirming the adolescent's lack of culpability.

Choice C rationale

Solely focusing on the future might dismiss the adolescent's current emotional needs and the process of working through their trauma. A balanced approach is necessary.

Choice D rationale

Actively monitoring the adolescent's relationships can demonstrate vigilance and support, helping to create a safe environment for recovery.

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A nurse is collecting data from a client who has schizophrenia.Which of the following client statements indicates that the client is experiencing a command hallucination?

Nursing Test Bank

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A nurse is collecting data from a client who has schizophrenia.
Which of the following client statements indicates that the client is experiencing a command hallucination?