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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Psychiatrist: Psychiatrists focus primarily on medical and pharmacological interventions for mental illnesses. While they play a crucial role in diagnosing and treating mental health conditions, they typically do not have the expertise in housing assistance or social services.

B. Behavioral therapist: Behavioral therapists focus on psychotherapeutic interventions to address and modify behavior. They are not typically involved in addressing social determinants of health, such as housing.

C. Social worker: Social workers are specifically trained to address social issues, including housing. They work with clients to assess their social needs, connect them with resources, and advocate for their well-being. In this case, a social worker would be instrumental in helping the client find housing resources and support.

D. Psychologist: Psychologists primarily focus on psychological assessments, therapy, and interventions. Like psychiatrists, their expertise is more centered around mental health treatment rather than addressing the social determinants of health such as housing.

A. hypotensive shock B. hypertensive crisis C. cardiac dysrhythmia D. cardiogenic shock

Correct Answer is B

Explanation

A. Hypotensive shock: This is not the correct answer. MAO inhibitors are not associated with causing hypotensive shock. In fact, they can lead to an increase in blood pressure.

B. Hypertensive crisis: This is the correct answer. MAO inhibitors interact with certain foods and drugs, such as those containing tyramine, leading to an increased risk of a hypertensive crisis. Foods rich in tyramine, such as aged cheeses, certain wines, and some processed meats, can cause a sudden and dangerous increase in blood pressure when combined with MAO inhibitors.

C. Cardiac dysrhythmia: While all medications have potential side effects, MAO inhibitors are not typically associated with causing cardiac dysrhythmias.

D. Cardiogenic shock: MAO inhibitors are not known to cause cardiogenic shock. The primary concern with MAO inhibitors is the potential for a hypertensive crisis due to interactions with specific foods and drugs.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which hallucination necessitates the nurse to implement safety measures? The patient says.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a mental illness and is without housing. The nurse should identify that which of the following interprofessional team members can help the client find housing?

Correct Answer is C

Explanation

A nurse instructs a patient taking a drug that inhibits monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of:

Correct Answer is B

Explanation

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?

A withdrawn client diagnosed with schizophrenia expresses little emotion and refuses to attend group therapy. What altered component of the nervous system should a nurse recognize as being implicated in this behavior?

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid: benztropine (Cogentin), 1 mg prn: and zolpidem (Ambien). 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

depressed client states. I have a chemical imbalance in my brain. I have no control over my behavior. Medications are my only hope to feel normal again. Which nursing response is appropriate?

Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders?

Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment?