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 ["A","B","C","E"]
Explanation
A. Delirium can cause difficulty recognizing objects, people, or places, which is a form of agnosia.
B. Patients with delirium often have fluctuating levels of consciousness, ranging from lethargy to hyperalertness.
C. Delirium commonly affects orientation, causing confusion about where they are or what time it is.
D. Apathy is more characteristic of depression or dementia rather than the acute, fluctuating attention seen in delirium.
E. Patients with delirium often display inattention and an inability to focus, leading to distractibility and wandering attention.
Correct Answer is A
Explanation
A. Haloperidol, a typical antipsychotic, commonly causes extrapyramidal side effects (EPS) such as muscle stiffness, rigidity, tremors, and sedation, which can make patients feel “robotic.”
B. Headache, watery eyes, and runny nose are not typical side effects of haloperidol; they are more consistent with allergy or upper respiratory symptoms.
C. Mild fever, sore throat, and skin rash could indicate a serious reaction such as agranulocytosis, which is rare and more common with atypical antipsychotics like clozapine.
D. Sweating, nausea, and diarrhea are not primary side effects of haloperidol; they may occur with other medications or conditions but are not typical EPS.
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