Which hallucination necessitates the nurse to implement safety measures? The patient says.
The voices are telling me to harm myself
I hear Voices
I see birds flying in the room
The voices don't stop and continue all day
The Correct Answer is A
A. The voices are telling me to harm myself: This statement indicates command hallucinations with a potential for harm. It suggests that the patient is receiving directives to harm themselves, which poses an immediate safety concern. Implementing safety measures, such as close monitoring, removal of harmful objects, and involving appropriate professionals, is essential to protect the patient from self-harm.
B. I hear voices: While hearing voices (auditory hallucinations) is a symptom that requires assessment and intervention, the nature of the voices is crucial in determining the level of risk. This statement, on its own, does not provide information about the content or potential harm associated with the voices.
C. I see birds flying in the room: This statement describes a visual hallucination, which, while potentially distressing, does not necessarily pose an immediate safety risk to the patient or others. Visual hallucinations may be less likely to necessitate immediate safety measures compared to command hallucinations.
D. The voices don't stop and continue all day: This statement suggests persistent auditory hallucinations, but without information about the content of the voices, it does not specifically indicate a risk of harm. While it may be distressing for the patient, the urgency for safety measures depends on the nature of the auditory content.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. By using a screening tool such as the CAGE questionnaire: This is the correct answer. The CAGE questionnaire is a widely used tool for screening alcohol use disorders. It consists of four questions that assess whether the individual has concerns or issues related to their alcohol consumption. A positive result may indicate a need for further assessment and intervention.
B. By asking directly if the client has ever had a problem with alcohol: While direct questioning is important, using a structured screening tool provides a more standardized and objective approach. The CAGE questionnaire offers specific questions that help identify potential issues with alcohol use.
C. By holistically assessing the client using the CINA scale: The CINA scale (Checklist of Nonverbal Indicators of Affect) is primarily used to assess nonverbal behaviors related to affect. While it may be useful in certain contexts, it is not specifically designed for assessing alcohol use disorders.
D. By referring the client for physician evaluation: While physician evaluation may be necessary for a comprehensive assessment, using a screening tool such as the CAGE questionnaire is an appropriate initial step. The results of the screening tool can guide further assessment and appropriate referrals.
Correct Answer is B
Explanation
A. fluoxetine (Prozac):
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression and anxiety disorders. While SSRIs can have side effects, significant alterations in cardiac or cerebral electrical conductivity and fluid/electrolyte imbalance are not typically associated with fluoxetine. The primary concerns with SSRIs are related to serotonin levels and can include gastrointestinal disturbances, insomnia, and sexual dysfunction.
B. Lithium (Lithobid):
This is the correct answer. Lithium is known to have potential side effects related to cardiac and cerebral function, as well as fluid and electrolyte balance. Monitoring blood levels of lithium is crucial to avoid toxicity, which can affect the cardiovascular and central nervous systems. Lithium toxicity can lead to symptoms such as tremors, confusion, ataxia, and, in severe cases, seizures.
C. venlafaxine (Effexor):
Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI) commonly used to treat depression and anxiety disorders. While it can cause some cardiovascular effects, the concern for significant alterations in cardiac or cerebral electrical conductivity and fluid/electrolyte imbalance is generally lower compared to lithium. The primary side effects of venlafaxine are related to serotonin and norepinephrine levels and may include increased blood pressure and heart rate.
D. clozapine (Clozaril):
Clozapine is an atypical antipsychotic medication used to treat schizophrenia. While antipsychotics can have side effects related to metabolic changes, significant alterations in cardiac or electrolyte imbalances are not typically associated with clozapine as the primary concern. Regular monitoring for metabolic side effects, such as weight gain and changes in lipid and glucose levels, is important with antipsychotic medications.
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