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 B
Explanation
A. This statement indicates that the client has abstained from alcohol while on haloperidol decanoate. This is a positive statement and shows compliance with recommendations, as alcohol can interact with medications and affect their effectiveness or cause adverse reactions. There is no immediate concern with this statement.
B. Haloperidol can increase sensitivity to sunlight (photosensitivity). Spending several hours outside gardening in the sun could potentially increase the risk of sunburn or other skin reactions due to photosensitivity. The nurse should address this statement by educating the client about the need to use sunscreen, wear protective clothing, and avoid prolonged sun exposure, especially during peak sunlight hours.
C. Regular monitoring of blood pressure is generally recommended for clients taking haloperidol, as it can occasionally cause hypotension (low blood pressure) as a side effect. Checking blood pressure once a week is a reasonable frequency, but the nurse should ensure that the client understands the signs and symptoms of hypotension and knows when to seek medical attention if blood pressure readings are abnormal.
D. Chewing sugar-free gum is generally not contraindicated while taking haloperidol. However, if the gum contains caffeine or other stimulants, it could potentially exacerbate certain side effects of the medication, such as tremors or restlessness. The nurse should inquire further about the type of gum being used and educate the client about potential interactions or side effects.
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.
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