A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?
Foot tapping and repeatedly writing the same phrase.
Detachment and overconfidence.
Euphoric mood, hyperactivity, distractibility.
Darting eyes, tilted head, mumbling to self.
The Correct Answer is D
A. Foot tapping and repeatedly writing the same phrase suggest compulsive or stereotypic behavior, not hallucinations.
B. Detachment and overconfidence may indicate personality or mood disturbances, but not hallucinations.
C. Euphoric mood, hyperactivity, and distractibility are signs of mania, not auditory hallucinations.
D. Darting eyes, tilted head, and mumbling to self are classic behaviors seen when a patient is responding to internal stimuli such as auditory hallucinations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This response is confrontational and judgmental, likely causing defensiveness rather than insight.
B. Pointing out defensiveness may provoke resistance rather than helping the patient analyze their behavior objectively.
C. This response encourages the patient to reflect on their own behavior and the consequences of drinking, promoting self-awareness and objective evaluation without judgment. It allows the patient to explore their actions and recognize patterns.
D. This response is accusatory and may make the patient feel blamed, which is not therapeutic.
Correct Answer is B
Explanation
A. Voluntary admission does not remove a patient’s right to refuse treatment; informed consent is still required for all medications and procedures.
B. Clients admitted voluntarily retain the right to make decisions about their care, including providing informed consent for treatments and medications. This statement accurately reflects the client’s rights.
C. Healthcare providers are not allowed to disclose patient admission information without consent; confidentiality is maintained.
D. Voluntary patients have the right to request discharge, usually with a short notice period, even before a formal discharge summary is completed.
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