A patient's care plan includes monitoring for auditory ...

[chandani]

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?
 
  a. Detachment and overconfidence
  b. Darting eyes, tilted head, mumbling to self
  c. Euphoric mood, hyperactivity, distractibility
  d. Foot tapping and repeatedly writing the same phrase

Question 2

Which hallucination necessitates the nurse to implement safety measures? The patient says,
 
  a. I hear angels playing harps.
  b. The voices say everyone is trying to kill me.
  c. My dead father tells me I am a good person.
  d. The voices talk only at night when I'm trying to sleep.

[Jmfn03]

Answer to Question 1

ANS: B
Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.

Answer to Question 2

ANS: B
The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.

[chandani]

TY

[Jmfn03]

Happy to Help