Which hallucination necessitates the nurse to implement safety measures? The patient says.
The voices are telling me to harm myself
I hear Voices
I see birds flying in the room
The voices don't stop and continue all day
The Correct Answer is A
A. The voices are telling me to harm myself: This statement indicates command hallucinations with a potential for harm. It suggests that the patient is receiving directives to harm themselves, which poses an immediate safety concern. Implementing safety measures, such as close monitoring, removal of harmful objects, and involving appropriate professionals, is essential to protect the patient from self-harm.
B. I hear voices: While hearing voices (auditory hallucinations) is a symptom that requires assessment and intervention, the nature of the voices is crucial in determining the level of risk. This statement, on its own, does not provide information about the content or potential harm associated with the voices.
C. I see birds flying in the room: This statement describes a visual hallucination, which, while potentially distressing, does not necessarily pose an immediate safety risk to the patient or others. Visual hallucinations may be less likely to necessitate immediate safety measures compared to command hallucinations.
D. The voices don't stop and continue all day: This statement suggests persistent auditory hallucinations, but without information about the content of the voices, it does not specifically indicate a risk of harm. While it may be distressing for the patient, the urgency for safety measures depends on the nature of the auditory content.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Allow the client to pace alone until physically tired: While pacing can be a coping mechanism, leaving the client alone may not be the most therapeutic approach. It is important for the nurse to provide support and assess the client's emotional state.
B. Walk with the client at a gradually slower pace: This is the correct answer. Walking with the client at a gradually slower pace allows the nurse to offer support and engage in therapeutic communication. It provides a calming presence and can assist the client in self-regulating their anxiety.
C. Have a staff member escort the client to her room: Escorting the client to her room might be perceived as restrictive or punitive. It is generally more beneficial to engage in supportive interventions and encourage coping strategies.
D. Instruct the client to sit down and stop pacing: Giving direct orders to stop pacing may increase anxiety and may not be an effective approach. It is often better to engage in a supportive manner and explore ways to help the client manage their anxiety.
Correct Answer is D
Explanation
A. Concern for others: Individuals with antisocial personality disorder typically lack genuine concern for others and may exploit or manipulate them for personal gain.
B. Actively engaged in all unit activities: While engagement in activities can vary, the key feature of antisocial personality disorder is not a high level of engagement but rather a disregard for rules and the rights of others.
C. Mindful of following all of the unit rules: Individuals with antisocial personality disorder often have a history of rule-breaking and may not be consistently mindful of following societal or institutional rules. They may engage in behaviors that violate rules or laws.
D. Manipulative: This is the correct answer. Antisocial personality disorder is characterized by manipulative behaviors, where individuals exploit others for personal gain or pleasure. Manipulation is a key feature of this disorder.
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