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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This technique involves allowing the client to remove themselves from the situation causing agitation temporarily. It is a de-escalation technique where the client can regain composure and reduce agitation by being alone or in a quieter environment. The nurse ensures the environment is safe and monitors the client during this time.
B. Restraint involves physically restricting the client's movement to prevent harm to themselves or others when they are in a state of extreme agitation and are at risk of causing harm. It is used as a last resort and typically requires a healthcare provider's order due to the potential risks and ethical considerations.
C. Diversion involves redirecting the client's attention away from the source of agitation to something else, such as a calming activity or a change of topic. It can help shift the client's focus and reduce escalating emotions.
D. Also known as a therapeutic restraint hold, this technique is used to safely manage a client who is agitated and may become physically aggressive. It involves trained staff using specific holds to restrain the client in a way that prevents harm while allowing for therapeutic communication.
Correct Answer is B
Explanation
A. This statement is incorrect. Under the Health Insurance Portability and Accountability Act (HIPAA) in the United States and similar privacy laws in other countries, healthcare providers are generally prohibited from disclosing a client's health information to their employer without the client's explicit consent.
B. This statement is correct. HIPAA and other privacy laws extend confidentiality protections beyond a client's death. Healthcare providers are still obligated to protect the confidentiality of deceased individuals' health information, unless certain exceptions apply (e.g., public health reasons or legal requirements).
C. Consent from a provider is not sufficient for discussing health information with a client's family; the consent must come from the client or their legal representative.
D. While it is generally good practice to obtain consent from the client before disclosing health information to their family members, there are circumstances where healthcare providers can share information with family members without consent.
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