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 D

Explanation

A. This scenario involves the issue of informed consent and medical ethics rather than libel. It pertains to the client's right to make decisions about their treatment. While administering medication without consent could have legal and ethical implications, it does not relate to libel.
B. This is an example of negligence or breach of duty, which could result in harm to the client. It pertains to safety protocols and standards of care rather than libel. Properly securing a client in a wheelchair is crucial for their safety and is not related to libel.
C. This example involves ethical considerations around coercion and restraint use. Threatening to apply restraints without a legitimate reason or following proper protocols could be considered a violation of

the client's rights. However, it does not constitute libel, as it does not involve false statements that harm someone's reputation through written or broadcasted communication.
D. This is an example of libel. Documenting false information about a client's substance use history can damage their reputation and potentially lead to negative consequences for the client, such as improper treatment or legal ramifications. Accurate and truthful documentation is essential in healthcare to ensure proper care and respect for the client's rights.

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.

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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 on a mental health unit is assisting with developing an in-service for staff members about legal issues. Which of the following examples should the nurse include as an example of libel?

Correct Answer is D

Explanation

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 caring for a client who is receiving acute care for the treatment of a substance use disorder. With which of the following actions is the nurse demonstrating the ethical principle of veracity?

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A nurse is assisting in the care of a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following is the nurse's role during the informed consent process?

A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency. The nurse should encourage the client to participate in which of the following groups?