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. Methadone (Methadose) is used as opioid replacement therapy to prevent withdrawal symptoms, not primarily to maintain abstinence.
B. Naltrexone (Vivitrol) is an opioid antagonist that helps maintain abstinence in patients with alcohol or opioid dependence by reducing cravings and blocking the euphoric effects of these substances.
C. Disulfiram (Antabuse) is used specifically for alcohol dependence; it causes unpleasant reactions if alcohol is consumed but does not address opioid addiction.
D. Bromocriptine (Parlodel) is used for Parkinson’s disease and certain endocrine disorders; it is not indicated for maintaining abstinence from alcohol or opioids.
Correct Answer is C
Explanation
A. Patients do not need to double fluid intake, just maintain adequate hydration (2–3 L/day). Drinking twice the usual amount could lead to fluid overload or dilute sodium balance.
B. Lithium should never be doubled. In fact, vomiting and diarrhea increase risk of lithium toxicity, so the provider must be notified instead.
C. Lithium excretion is closely tied to sodium and fluid balance. A stable diet with normal salt and adequate fluid intake helps prevent fluctuations in lithium levels and reduces risk of toxicity.
D. Avoiding aged cheese, processed meats, and red wine is teaching for MAOI therapy (to prevent hypertensive crisis due to tyramine), not for lithium.
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