A nurse is collecting data from a client who has schizophrenia.
Which of the following client statements indicates that the client is experiencing a command hallucination? .

"The aliens are going to abduct me tonight.”.

"The voices told me to quit eating the food here.”. .

"Are you planning to kill me?" .

"Can you see these spiders crawling all over me?" .

Answer and Explanation

The Correct Answer is B

Choice A rationale:

This statement indicates a delusion, not a command hallucination. Delusions are fixed false beliefs that are not based in reality.

Choice B rationale:

This statement indicates a command hallucination. Command hallucinations involve hearing voices that direct the person to take action.

Choice C rationale:

This statement indicates paranoia, not a command hallucination. Paranoia involves intense anxious or fearful feelings and thoughts often related to persecution or threat.

Choice D rationale:

This statement indicates a visual hallucination, not a command hallucination. Visual hallucinations involve seeing things that aren’t there.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Potential Provider Prescription	Expected or Unexpected?	Explanation
Administer acyclovir.	Unexpected	Acyclovir is an antiviral medication used to treat infections like herpes simplex virus (HSV) and varicella-zoster virus (VZV). The client’s confusion, agitation, and hallucinations do not suggest a viral infection as the primary cause.
Administer lorazepam.	Expected	Lorazepam is a benzodiazepine that can be used for acute agitation, anxiety, or delirium-related distress. Since the client is agitated and confused, lorazepam is an appropriate intervention.
Initiate 1:1 supervision.	Expected	The client is confused, agitated, and hallucinating, which increases the risk of self-harm, wandering, or injury. 1:1 supervision ensures safety.
Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.	Expected	The client has dry mucous membranes, suggesting possible dehydration, which can contribute to confusion and agitation. IV fluids help restore hydration.

A. . Make a personal introduction to the client at each interaction. B. Give the client a list of foods to choose from for dinner. C. Repeat orientation questions until the client gives a correct response. D. Provide the client with a dark environment for sleeping.

Correct Answer is A

Explanation

Choice A rationale:

Making a personal introduction to the client at each interaction is a recommended approach for clients with dementia. It helps to orient the client and establish a connection, which can reduce confusion and anxiety.

Choice B rationale:

Giving a client with dementia a list of foods to choose from for dinner may be overwhelming due to impaired decision-making abilities.

Choice C rationale:

Choice D rationale:

Providing a dark environment for sleeping can be disorienting for a client with dementia. A low level of light can help the client maintain orientation to their surroundings.

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A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination? .

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Naxlex Comprehensive Predictor Exams

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400. Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?.

Correct Answer is A

Explanation

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A nurse is collecting data from a client who has schizophrenia.
Which of the following client statements indicates that the client is experiencing a command hallucination? .