A patient who is experiencing auditory hallucinations has become increasingly agitated throughout the day. The patient suddenly kicks over an empty trash can and shouts “I WILL KILL YOU ALL!” at the wall. In response, the nurse should (Select all that apply).

Speak with a very loud voice so that the patient can hear.

Ensure there is adequate space between nurse and patient.

Approach the patient in a calm manner.

Ensure the patient is safely locked in their room.

Give the patient a detailed explanation of all unit policies.

Answer and Explanation

Correct Answer : B,C

A: Speaking loudly can escalate the patient’s agitation and is not recommended. A calm and soothing tone is more effective.

B: Ensuring adequate space between the nurse and the patient helps maintain safety and reduces the risk of physical harm.

C: Approaching the patient in a calm manner helps de-escalate the situation and provides reassurance to the patient.

D: Locking the patient in their room can increase their agitation and feelings of isolation. It should only be considered if the patient poses an immediate threat to themselves or others and other de-escalation techniques have failed.

E: Providing a detailed explanation of unit policies is not appropriate in the moment of crisis. The focus should be on immediate de-escalation and ensuring safety.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Determine if the medication can be switched to a difficult-to-conceal form (e.g., liquid, fast-dissolving tablet). B. Address underlying reasons for not wanting to take medications. C. Assess for delusions and hallucinations once a shift. D. Administer medications in a seclusion room so they can be closely monitored. E. Don’t allow the patient to attend group activities if medication was not taken.

Correct Answer is ["A","B"]

Explanation

A: Switching to a difficult-to-conceal form of medication can help ensure that the patient takes their medication as prescribed. Liquid or fast-dissolving tablets are harder to hide or spit out.

B: Addressing the underlying reasons for not wanting to take medications is crucial for understanding the patient’s perspective and finding solutions that encourage adherence.

C: While assessing for delusions and hallucinations is important, it is not directly related to ensuring medication adherence.

D: Administering medications in a seclusion room is not a standard practice and can be seen as punitive. It should only be used if the patient poses a risk to themselves or others.

E: Not allowing the patient to attend group activities if medication was not taken can be counterproductive and may increase the patient’s resistance to treatment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A patient who is experiencing auditory hallucinations has become increasingly agitated throughout the day. The patient suddenly kicks over an empty trash can and shouts “I WILL KILL YOU ALL!” at the wall. In response, the nurse should (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient reports that they had been using oxycodone recreationally, last use was about a day ago. The patient is concerned they are experiencing withdrawal. What would the nurse expect to observe in opioid withdrawal?

Correct Answer is A

Explanation

A patient with schizophrenia has been admitted to an inpatient facility. Since admission, the patient has been either refusing medication or cheeking their medications. What interventions should the nurse implement? Select all that apply.

Correct Answer is ["A","B"]

Explanation

A patient with borderline personality disorder has cut her wrists while on the unit. Which of the following is NOT an appropriate nursing intervention?

A client with antisocial personality disorder has a history of responding to frustration by being verbally abusive. How would the nurse manage this behavior? Select all that apply.

A nurse is caring for an adolescent who fainted at school. When interviewing the family, which statement by the mother best aligns with the diagnosis of bulimia?

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?

A new nurse is preparing to assess a patient who is experiencing auditory hallucinations. Which statement by the nurse requires follow-up?

A school-aged patient with attention-deficit/hyperactivity disorder is entering day treatment. During the initial office visit, the mental health nurse anticipates the patient will exhibit which of the following behaviors? Select all that apply.

A nurse is working with a client who routinely lies to staff, refuses to comply with unit rules, and shows no remorse for the people they have harmed with their behavior. These behaviors best describe what personality disorder?

The nurse is working with the family of a child diagnosed with autism spectrum disorder. What would be an appropriate intervention for the family?