Question

the nurse is caring for a patient who reports hearing a voice telling her, \you are horrible and i hope you die.\ how should the nurse document this assessment finding in the patients chart?

the patient is having an illusion.
the patient is concretely thinking.
the patient is having auditory hallucinations.
the patient is having a delusion of persecution.

Explanation:

Analyze the patient's clinical presentation

The patient reports hearing a voice telling her, "You are horrible and I hope you die." This represents a sensory perception in the absence of any external physical stimulus.

Differentiate psychiatric assessment terms

• Illusion: A misinterpretation of a real external sensory stimulus (e.g., mistaking a coat hanger for a person).
• Concrete thinking: A style of thinking characterized by a literal interpretation of words and a lack of abstract reasoning.
• Auditory hallucination: A sensory perception of hearing sounds or voices when no external sound is present.
• Delusion of persecution: A false, fixed belief that one is being harassed, cheated, or conspired against, which is a thought content alteration rather than a sensory perception.

Select the correct documentation finding

Hearing a voice in the absence of an external stimulus is classified as an auditory hallucination. Therefore, the nurse should document this finding as "The patient is having auditory hallucinations."

Answer:

• (A) The patient is having an illusion.
• (B) The patient is concretely thinking.
• (C) The patient is having auditory hallucinations. (Correct answer)
• (D) The patient is having a delusion of persecution.