A patient's nursing care plan includes assessment for auditory ...

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A patient's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the patient may be hallucinating include:
 
  a. aloofness, increased distractibility, and suspicion.
  b. elevated mood, hypertalkativeness, and distractibility.
  c. performing rituals and avoiding open places.
  d. darting eyes, distracted, and mumbling to self.

Question 2

According to the values of cultures whose members use folk healing practices, features most important for a nurse to possess include: (Select all that apply.)
 
  a. ethnocentrism.
  b. cultural skill.
  c. cultural desire.
  d. cultural knowledge.
  e. academic credentials.
  f. respect for persons.

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Answer to Question 1

D
Clues to hallucinations include eyes looking around the room as though to find the speaker, appearing preoccupied or distracted, and grimacing, mumbling, or talking aloud as though responding conversationally to someone. Mood changes, ritualistic behavior, and aloofness are not indicators of hallucinations.

Answer to Question 2

B, C, D, F
Cultural skill allows the nurse to make culturally sensitive assessments and plan for care. Cultural desire refers to willingness to learn from the patient. Cultural knowledge alerts the nurse to areas where cultural differences may be present, helps with understanding, and reduces misinterpretations. Respect for persons is important to members of all cultures and part of cultural desire. Ethnocentrism may result in imposing the nurse's cultural norms on a patient. Academic credentials are not of concern because curative factors focus on folk healing. More important are collaboration with cultural translators and extensive involvement with the family and the community when delivering education and making treatment plans.

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