Which hallucination necessitates the nurse to implement safety measures? The patient says,
a. "I hear angels playing harps."
b. "The voices say everyone is trying to kill me."
c. "My dead father tells me I am a good person."
d. "The voices talk only at night when I'm trying to sleep."
ANS: B
The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.
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