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. Correct. Using the proportion, the correct dose of fluoxetine (Prozac) for the prescribed 60 mg is 15 mL.
B. Incorrect. This is not the correct dose. The correct dose is 15 mL, not 20 mL.
C. Incorrect. This is not the correct dose. The correct dose is 15 mL, not 25 mL.
D. Incorrect. This is not the correct dose. The correct dose is 15 mL, not 10 mL.
Correct Answer is A
Explanation
A. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."
This response is empathetic and invites the client to discuss their concerns. However, it doesn't explicitly address the client's request for the nurse to take action. The more appropriate approach would involve the nurse taking direct responsibility for addressing the issue.
B. "Why are you overreacting to the issue?"
This response may be perceived as dismissive and judgmental. It does not validate the client's concerns or address the issue constructively.
C. "You should bring this to the attention of your treatment team."
While involving the treatment team is important, the client has directly approached the nurse with a concern. It is appropriate for the nurse to take the initial step in addressing the issue directly rather than immediately redirecting the client to the treatment team.
D. "I'll talk to Peter and present your concerns."
This is the most appropriate response. It acknowledges the client's concerns, takes responsibility for addressing the issue, and ensures that the client's voice is heard. The nurse can discuss the matter with Peter and work towards a resolution.
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