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 B
Explanation
A. Mild anxiety usually presents with slight discomfort, restlessness, or irritability, and the client remains able to focus and problem-solve.
B. Severe anxiety is characterized by physical symptoms such as chest pain, headache, shortness of breath, and a preoccupation with specific concerns (e.g., personal problems) that limit the client’s ability to focus on other matters.
C. Panic involves sudden, intense terror or dread, often accompanied by inability to communicate or function, and may include distorted perceptions or irrational behavior. The client in this scenario can still verbalize concerns.
D. Moderate anxiety causes narrowing of attention and some tension or restlessness, but the physical manifestations and preoccupation in this scenario indicate a more severe level.
Correct Answer is B
Explanation
A. The patient’s symptoms are physiological and neurological, not intentional behaviors for attention.
B. Alcohol withdrawal delirium (delirium tremens) typically occurs 48–72 hours after the last drink and includes tremors, agitation, anxiety, diaphoresis, tachycardia, hallucinations, and nightmares—all present in this patient.
C. Although head injury can cause confusion and agitation, the timing of symptoms following alcohol withdrawal aligns more closely with delirium tremens.
D. Acute psychosis can present with hallucinations, but in this case, the onset following alcohol cessation and accompanying autonomic hyperactivity point toward alcohol withdrawal delirium.
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