A patient tried to gouge out his eye in response to auditory ...

[kshipps]

A patient tried to gouge out his eye in response to auditory hallucinations commanding, If thine eye offends thee, pluck it out. The nurse would analyze this behavior as indi-cating:
 
  a. Derealization
  b. Inappropriate affect
  c. Impaired impulse control
  d. Inability to manage anger

Question 2

A 19-year-old patient is admitted for the second time in 9 months and is acutely psy-chotic with a diagnosis of undifferentiated schizophrenia.
 
  The patient sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associ-ated with the patient's condition as:
  a. Social isolation
  b. Disturbed thinking
  c. Altered mood states
  d. Poor impulse control

[Heffejeff]

Answer to Question 1

ANS: C
Command hallucinations may be so intense that the patient cannot control the impulse to do what the hallucination tells him to do; thus the patient has impaired impulse control. This is not an anger management problem. Derealization is a feeling that the environment is distorted or unreal and not suggested in the scenario. No evidence of inappropriate affect is given.

Answer to Question 2

ANS: B
The nurse interprets the patient's statements that were not reality-based as indicating dis-turbed thought processes. Social isolation is not the primary patient problem. No data exist to support the other options.