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 C

Explanation

A. Singing carols is calm, unlikely to trigger combat-related flashbacks.
B. A seashore outing is generally peaceful and not typically a PTSD trigger.
C. Fireworks mimic gunfire and explosions, which can easily trigger flashbacks, hypervigilance, and distress in combat veterans with PTSD.
D. Halloween can be stimulating, but not as direct a combat reminder as fireworks.

A. "The most common side effects are directly related to the use of anesthesia." B. The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss." C. "Most clients have no adverse effects to this treatment, but muscle cramping may result from the induced seizure." D. "Some clients have been known to have a myocardial infarction, but we will monitor your spouse closely to be certain this does not happen."

Correct Answer is B

Explanation

A. While anesthesia is used, the side effects from it are not the main concern with ECT.
B. The most common side effects are mild confusion, headache, and short-term memory loss, which are typically temporary.
C. Muscle relaxants are given before the procedure to prevent cramping or injury from the seizure.
D. Myocardial infarction is not a common side effect; this response could unnecessarily alarm the spouse.

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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 soldier returned 3 months ago from a combat zone and was diagnosed with post-traumatic stress disorders (PTSD). Which social event would be most disturbing for this soldier?

Correct Answer is C

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Correct Answer is B

Explanation

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