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. Suicide precautions should never be discontinued at this time; in fact, suicide risk is highest when energy improves before mood fully stabilizes.
B. Increased energy after starting antidepressants raises suicide risk, as the patient may now have the ability to act on suicidal thoughts. Continuous supervision is the priority for safety.
C. Discharge planning is premature at this stage; safety comes first.
D. Art and music therapy may be beneficial long-term but do not address the immediate suicide risk.
Correct Answer is B
Explanation
A. Confidentiality does not end when a client dies; healthcare professionals are still required to protect the privacy of medical records and disclosures.
B. This reflects the "duty to warn" principle (Tarasoff ruling), which legally obligates providers to take reasonable steps to protect identifiable individuals if a client poses a threat of harm. This is a recognized exception to confidentiality.
C. Healthcare workers must comply with court orders or subpoenas requesting medical information. Refusing is not legally permissible.
D. Attorneys do not automatically have access to client information; a legal order is required. Confidentiality is not broken based on an attorney’s request alone.
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