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 D

Explanation

A. This disorder is characterized by sudden, rapid, recurrent motor movements and vocal tics, not slow, writhing movements caused by long-term antipsychotic use.

B. This is a dangerous reduction in white blood cells, typically presenting with fever, sore throat, or infections, not abnormal involuntary movements.

C. Anticholinergic side effects include dry mouth, blurred vision, constipation, urinary retention, not the repetitive, involuntary movements seen here.

D. This condition is a late-onset side effect of long-term use of antipsychotics, especially first-generation drugs like fluphenazine. It presents as grimacing, lip smacking, and slow, writhing movements of the neck and shoulders, consistent with the patient’s symptoms.

A. Amnesiac Syndrome B. Alzheimer's Disease C. Delirium D. Dementia

Correct Answer is C

Explanation

A. This involves memory loss due to brain injury or alcohol abuse, not acute fluctuating confusion.

B. Alzheimer’s causes progressive, irreversible memory decline that develops gradually, not suddenly over 2 days.

C. Delirium is characterized by acute onset, fluctuating levels of orientation, confusion, speech changes, and impaired gait, often triggered by medications, infections, or metabolic issues.

D. Dementia develops slowly and progressively, not suddenly like delirium.

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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

A patient diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse's notes that the patient grimaces and is constantly smacking his lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?

Correct Answer is D

Explanation

An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady galt, and fluctuating levels of orientation. These findings are most characteristics of

Correct Answer is C

Explanation

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