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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. This is a crucial first step in recovery. It involves recognizing and accepting that one has lost control over their drinking and that alcohol use is causing negative consequences in their life. Without acknowledging this lack of control, individuals may not be motivated to seek or engage in treatment.
B. While medications such as disulfiram (Antabuse) or naltrexone (Revia) can be part of a comprehensive treatment plan for alcohol use disorder, agreeing to a prescription for an alcohol use deterrent is not typically the first step in recovery. It usually follows assessment, acknowledgment of the problem, and development of a treatment plan in collaboration with healthcare providers.
C. Building a strong support network is indeed crucial for long-term recovery. This network may include family, friends, peers in recovery, and support groups like Alcoholics Anonymous (AA). However, forming this support network is often a step that occurs as part of ongoing treatment and recovery efforts rather than the very first step.

D. Incorporate a form of spirituality into daily life: Spirituality or a sense of purpose can be a significant component of recovery for some individuals, providing strength and motivation. However, it is not universally considered the first step in recovery. Spirituality may be explored and integrated into the recovery journey as individuals progress in treatment and self-discovery.

A. Verbally de-escalate the client. B. Obtain a prescription for haloperidol. C. Place the client in restraints. D. Take the client to the seclusion room.

Correct Answer is A

Explanation

A. Verbal de-escalation involves using calm, non-confrontational communication techniques to help calm the client. This can include speaking softly, using non-threatening body language, and actively listening to the client's concerns. It is the first-line intervention for managing escalating behavior because it aims to reduce agitation without the use of physical or chemical restraints.
B. Haloperidol is an antipsychotic medication that may be prescribed for acute agitation and aggression in some situations. However, obtaining a prescription requires provider authorization and should not be the first intervention unless the client's agitation poses an immediate threat to safety and verbal de- escalation has been ineffective. It is typically used when other interventions have not successfully managed agitation.

C. Physical restraints should only be used as a last resort and in accordance with institutional policies and legal guidelines. Restraints are intended to prevent harm to the client or others when all other methods of de-escalation have failed and there is an imminent risk of harm. Placing a client in restraints without attempting verbal de-escalation first can escalate the situation further.
D. Seclusion is also a restrictive intervention that should be used judiciously and only when necessary to protect the client or others from harm. It involves placing the client in a designated, secure area where they can be monitored closely. Similar to physical restraints, seclusion should be considered only after attempts at verbal de-escalation have been unsuccessful and there is a clear risk of harm.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?

Correct Answer is A

Explanation

A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a group of clients in a pediatric clinic. Which of the following clients is at highest risk for physical abuse?

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?

A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?

A nurse is contributing to the plan of care for a client who has acute delirium. Which of the following interventions should the nurse include in th plan of care?

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.

A nurse is collecting data from a client who is taking lithium. Which of the following findings should the nurse identify as early manifestations of lithium toxicity? (Select all that apply.)

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?