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. "After I clean your wounds, I would like for you to journal how you were feeling before you cut yourself."
This response is the most therapeutic. It acknowledges the patient's self-harm behavior, addresses the immediate physical needs by offering to clean the wounds, and encourages the patient to reflect on their emotions through journaling. This approach promotes self-awareness and provides a constructive coping strategy.
B. "I’m so sorry you cut your arms. Let's discuss how you were feeling."
This response is empathetic and encourages communication about the patient's emotions. While it acknowledges the self-harm and invites discussion, it does not suggest a specific coping strategy like journaling. It is still a supportive and therapeutic approach.
C. "Wow. What happened to you?"
This response may come off as judgmental or dismissive. It does not acknowledge the patient's emotional state or offer immediate support for the physical wounds. The tone and wording may make the patient feel uncomfortable or judged.
D. "What did you use to cut yourself! I will need to search your room."
This response is not therapeutic and may be perceived as confrontational and invasive. It does not prioritize the patient's emotional well-being and may violate the patient's trust and privacy. Searching the room without consent is not a recommended approach.
Correct Answer is D
Explanation
A. Risperidone (Risperdal):
Risperidone is an atypical antipsychotic and generally has a lower propensity for causing anticholinergic side effects compared to typical antipsychotics.
B. Lithium (Lithobid):
Lithium is a mood stabilizer used primarily for bipolar disorder and does not typically cause anticholinergic side effects.
C. Buspirone (Buspar):
Buspirone is an anxiolytic medication and does not have significant anticholinergic properties. It tends to have fewer side effects compared to other medications used for anxiety.
D. Fluphenazine (Prolixin):
Fluphenazine is a typical antipsychotic medication and belongs to the phenothiazine class, which is known to have notable anticholinergic effects. These effects can include dry mouth, constipation, blurred vision, urinary retention, and cognitive impairment.
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