A patients care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?

Correct Answer: B

Rationale: In the context of psychobiological disorders, auditory hallucinations are a common symptom seen in conditions like schizophrenia. Option B, which includes "darting eyes, tilted head, mumbling to self," suggests the patient may be experiencing auditory hallucinations. Darting eyes and tilted head could indicate that the patient is hearing things that are not present in their environment, leading to a distracted and disoriented state where they may be responding to the hallucinations by mumbling to themselves. Option A, detachment and overconfidence, does not directly correlate with auditory hallucinations. Detachment could be a symptom of dissociative disorders, while overconfidence might be seen in conditions like bipolar disorder or narcissistic personality disorder. Option C, euphoric mood, hyperactivity, and distractibility, are more indicative of conditions like bipolar disorder or ADHD rather than auditory hallucinations. Option D, foot tapping and repeatedly writing the same phrase, may suggest symptoms related to anxiety or obsessive-compulsive disorder, but do not specifically point towards auditory hallucinations. Educationally, understanding the specific manifestations of symptoms in psychobiological disorders is crucial for accurate assessment and intervention. Recognizing the unique signs of auditory hallucinations can help healthcare professionals provide appropriate care and support for patients experiencing these symptoms.

Correct Answer: D

Rationale: When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patients anxiety rises until trust is established. There is no evidence that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is untrue that withdrawn patients with schizophrenia are commonly violent or exhibit a high degree of hostility by demonstrating rejecting behavior.

Correct Answer: D

Rationale: Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a relationship with the nurse. The therapeutic technique is offering self. Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building. The incorrect responses would be difficult for a person with profound depression to believe, provide false reassurance, and are counterproductive. The patient is unable to say positive things at this point.

Correct Answer: B

Rationale: In the context of major depression and feelings of worthlessness, the priority intervention for a patient is careful unobtrusive observation around the clock, which is option B. This intervention is crucial because individuals with major depression are at risk for self-harm, including suicidal ideation or attempts. Continuous observation ensures the safety and well-being of the patient by allowing for early detection of any signs of suicidal behavior or deterioration in mental health. Option A, distracting the patient from self-absorption, may not address the underlying issues of major depression and feelings of worthlessness. It could potentially minimize the patient's feelings rather than helping them work through and process their emotions. Option C, allowing the patient to spend long periods alone in meditation, may not be appropriate for someone dealing with major depression and feelings of worthlessness. While mindfulness practices can be beneficial, isolation may exacerbate feelings of worthlessness and lead to further withdrawal from social support systems. Option D, providing opportunities for assuming a leadership role, may not be suitable for a patient experiencing major depression. This approach could add pressure and stress to the individual, potentially worsening their mental health condition. Educationally, understanding the rationale behind prioritizing careful observation for individuals with major depression emphasizes the importance of safety and risk assessment in psychiatric care. It underscores the need for tailored interventions that address the specific challenges and vulnerabilities associated with different mental health disorders.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Urinary retention. Imipramine is a tricyclic antidepressant that can cause anticholinergic side effects such as urinary retention. This side effect can be potentially hazardous as it can lead to complications like urinary tract infections, bladder distention, or even renal issues. Dry mouth (option A) is a common side effect of imipramine but is typically not considered as hazardous as urinary retention. Blurred vision (option B) can occur due to the anti-cholinergic effects of the medication but is not as immediately concerning as urinary retention. Nasal congestion (option C) is not a typical side effect of imipramine and is not directly related to potential hazardous effects of the medication. Educationally, understanding the side effects of psychiatric medications is crucial for nurses and healthcare providers to ensure patient safety and well-being. Recognizing potentially hazardous side effects promptly and taking appropriate actions, such as collaborating with the healthcare provider, is essential in providing quality patient care.