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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Using silence allows the patient time to process thoughts and feelings, encourages introspection, and can facilitate deeper communication during interviews.

B. While prolonged silence can sometimes make patients uncomfortable, its intentional and therapeutic use is beneficial when appropriately timed.

C. Reflecting or paraphrasing communicates understanding; silence alone does not confirm comprehension.

D. In therapeutic communication, the nurse does not have to immediately fill silence; allowing moments of quiet can be purposeful.

A. distorted thought self-control. B. sleep pattern stabilization, C. interest in the environment. D. developing an optimistic outlook.

Correct Answer is A

Explanation

A. Clients experiencing grandiose thinking during acute mania often have inflated self-esteem and unrealistic ideas of ability or importance, making controlling or monitoring their thoughts a priority nursing outcome.

B. While sleep disturbances are common in mania, this outcome does not directly address grandiose thinking.

C. Increased engagement in the environment may occur, but it is not the primary expected outcome for controlling grandiose thoughts.

D. Optimism may be present, but grandiosity involves exaggerated self-perceptions rather than realistic optimism.

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A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions?

Correct Answer is A

Explanation

Which outcome is expected for a client experiencing grandiose thinking associated with acute mania?

Correct Answer is A

Explanation

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