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."

"The voices told me to quit eating the food”

"Are you planning to kill me?"

Answer and Explanation

The Correct Answer is C

A.   This statement describes a visual hallucination (seeing spiders crawling), not a command hallucination. Visual hallucinations involve seeing things that are not actually present.

B.   This statement reflects a delusion rather than a hallucination. Delusions are false beliefs that are firmly held despite evidence to the contrary. In this case, the belief in aliens and abduction is not related to hearing voices commanding actions.
C.   This statement indicates a command hallucination. The client hears voices instructing them to stop eating. Command hallucinations often involve direct, imperative commands from voices that are perceived as real.
D.   This statement reflects paranoia or fear of harm from others, which can be a common symptom in schizophrenia. However, it does not directly indicate a command hallucination.

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Correct Answer is ["2.5"]

Explanation

To administer the correct dose of sertraline, which is 50 mg, when the available oral solution concentration is 20 mg/mL,

Volume = Dose / Concentration.

So, for a 50 mg dose using a 20 mg/mL solution, the calculation would be 50 mg divided by 20 mg/mL, resulting in 2.5 mL.

Therefore, the nurse should administer 2.5 mL of the sertraline oral solution.

A. Allow the client to choose activities for the day. B. Redirect client behavior by initiating physical exercise. C. Encourage the client to spend time with others D. Be specific when explaining care to the client.

Correct Answer is D

Explanation

A. Allowing the client to choose activities may lead to decision fatigue or overwhelm due to the manic state.
B. Initiating physical exercise could help in redirecting excess energy, but it must be carefully monitored.
C. Encouraging the client to spend time with others might increase stimulation and potentially exacerbate the mania.
D. Clarity and specificity in communication are essential when caring for a client experiencing mania. Manic episodes can affect a client's ability to concentrate and process information. Providing clear instructions and explanations helps ensure the client understands what is expected and can follow through with necessary self-care and treatment activities.

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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

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.

Correct Answer is ["2.5"]

Explanation

A nurse is assisting in the care of a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take to promote a therapeutic environment?

Correct Answer is D

Explanation

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