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?" .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
A timeout is a de-escalation technique where the client is allowed to spend time alone in a safe environment to regain control.
Choice B rationale:
Restraint is not a de-escalation technique. It is a last resort measure used when other methods have failed and the client is a danger to themselves or others.
Choice C rationale:
Diversion is a technique used to distract the client from a stressful situation, not a de-escalation technique.
Choice D rationale:
A therapeutic hold is a type of physical restraint, not a de-escalation technique.
Correct Answer is C
Explanation
Choice A rationale:
Obtaining a prescription for haloperidol is not the first intervention the nurse should implement. Medication should be considered only after non-pharmacological interventions have been attempted.
Choice B rationale:
Taking the client to the seclusion room is not the first intervention the nurse should implement. Seclusion should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.
Choice C rationale:
Verbally de-escalating the client is the first intervention the nurse should implement. This involves using calm, clear communication to help the client regain control of their emotions.
Choice D rationale:
Placing the client in restraints is not the first intervention the nurse should implement. Restraints should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.
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