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 symptom

The patient reports hearing a voice when no external physical stimulus is present. This sensory perception in the absence of external stimuli is the definition of a hallucination. Since it involves hearing, it is classified specifically as an auditory hallucination.

Differentiate from other options

• An illusion is a misinterpretation of a real external sensory stimulus.
• Concrete thinking is a cognitive impairment where the patient is unable to think abstractly.
• A delusion is a fixed, false belief not amenable to change in light of conflicting evidence, rather than a sensory perception.

Select the correct documentation

The nurse must document this finding objectively as an auditory hallucination.

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.