A nurse in an acute mental health facility is assessing a client who is experiencing auditory command hallucinations. Which of the following questions should the nurse ask first?

"Can you tune out the voices by listening to music?"

"Are you also seeing unusual persons or things?"

"What are the voices telling you to do?"

"Do the voices cause you to feel anxious?"

Answer and Explanation

The Correct Answer is C

Rationale:

A. "Can you tune out the voices by listening to music?": This question focuses on coping strategies, which is important, but it is not the immediate priority. The nurse must first assess the content of the hallucinations to determine potential risk.

B. "Are you also seeing unusual persons or things?": Assessing for visual hallucinations is useful, but the client is currently experiencing auditory command hallucinations. Immediate focus should be on the commands to ensure safety.

C. "What are the voices telling you to do?": Determining the content of the voices is the priority because command hallucinations may instruct the client to harm themselves or others. Assessing risk and ensuring safety comes before exploring coping or additional symptoms.

D. "Do the voices cause you to feel anxious?": Assessing emotional response is relevant, but it is secondary to understanding whether the hallucinations pose a safety risk to the client or others.

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Correct Answer is C

Explanation

Rationale:

A. The client takes a hot bubble bath every day: Frequent hot bubble baths can irritate the skin and mucous membranes, potentially increasing the risk of infections. Daily bathing is acceptable, but water should be warm rather than hot, and bubble baths should be limited.

B. The client washes her perineum first when bathing: Proper hygiene involves washing from front to back to prevent transferring bacteria from the rectal area to the urethra or vagina. Washing the perineum first without this technique increases the risk of urinary tract infections.

C. The client brushes her teeth twice daily: Brushing teeth twice daily is an appropriate and effective oral hygiene practice. It helps prevent dental plaque, cavities, and gum disease, indicating correct understanding of personal hygiene.

D. The client wipes back to front when toileting: Wiping back to front can transfer fecal bacteria to the urethra and genital area, increasing the risk of urinary tract infections. The correct technique is front to back.

A. "Use an electric razor when shaving while taking this medication." B. "Take a dose of the medication every 5 minutes for a maximum of three doses" C. "Avoid taking this medication with milk products." D. "This medication can cause hearing loss."

Correct Answer is A

Explanation

Rationale:

A. "Use an electric razor when shaving while taking this medication.": Warfarin is an anticoagulant that increases the risk of bleeding. Using an electric razor reduces the risk of cuts and subsequent bleeding, which is an important safety measure for clients on warfarin therapy.

B. "Take a dose of the medication every 5 minutes for a maximum of three doses": This instruction is inappropriate and unrelated to warfarin. Warfarin is taken orally once daily, and frequent dosing in short intervals could lead to serious bleeding complications.

C. "Avoid taking this medication with milk products.": Milk does not significantly affect warfarin absorption or activity. The client should be cautioned about foods high in vitamin K, such as leafy greens, because they can interfere with warfarin’s anticoagulant effect.

D. "This medication can cause hearing loss.": Hearing loss is not a known adverse effect of warfarin. The primary concerns are bleeding risks, bruising, and interactions with other medications or foods.

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A nurse in an acute mental health facility is assessing a client who is experiencing auditory command hallucinations. Which of the following questions should the nurse ask first?

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