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. WBC count 3,300/mm³.
Clozapine, an atypical antipsychotic medication, is associated with a risk of agranulocytosis, which is a severe reduction in white blood cell (WBC) count. A WBC count of 3,300/mm³ is significantly below the normal range, and it indicates a contraindication to the use of clozapine.
B. Asthma:
Asthma is not a contraindication to clozapine. However, it is important to monitor respiratory function as antipsychotic medications can have side effects related to respiratory function.
C. Hypertension:
Hypertension alone is not a contraindication to clozapine. Clozapine can, however, be associated with some cardiovascular side effects, so blood pressure should be monitored regularly.
D. Fasting blood glucose 120 mg/dL:
An elevated fasting blood glucose level is not a contraindication to clozapine. However, it is important to monitor metabolic parameters as antipsychotic medications, including clozapine, can be associated with metabolic side effects.
Correct Answer is B
Explanation
A. Incorrect. Falling asleep in the chair and refusing to eat lunch is not indicative of tardive dyskinesia (TD). TD is characterized by involuntary movements, not by changes in sleep patterns or appetite.
B. Correct. Grimacing and lip smacking are characteristic movements associated with tardive dyskinesia. TD is a side effect of long-term use of typical antipsychotic medications, and it involves involuntary, repetitive movements, often involving the face and mouth.
C. Incorrect. Excessive salivation and drooling are not specific to tardive dyskinesia. These symptoms may occur due to various reasons, and TD is primarily associated with abnormal, involuntary movements.
D. Incorrect. Experiencing muscle rigidity and tremors is more characteristic of other side effects or conditions, such as extrapyramidal symptoms, but it is not specific to tardive dyskinesia. TD typically involves repetitive, involuntary movements rather than tremors.
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