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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Disulfiram: Disulfiram is used to support alcohol abstinence by causing unpleasant reactions when alcohol is consumed. It does not reverse opioid overdose and is not indicated for morphine toxicity.
B. Naloxone: Naloxone is an opioid antagonist that binds to opioid receptors and rapidly reverses the effects of morphine and other opioids. It is the first-line treatment for opioid overdose, effectively restoring respiratory function and alertness.
C. Activated charcoal: Activated charcoal can adsorb certain ingested toxins in the gastrointestinal tract, but it is not effective for opioids already absorbed systemically, such as in a morphine overdose.
D. Flumaren: Flumazenil (Flumaren) is a benzodiazepine antagonist used to reverse benzodiazepine overdose, not opioid toxicity. It has no effect on morphine or other opioids.
Correct Answer is D
Explanation
Rationale:
A. Lack of empathy: This is characteristic of narcissistic personality disorder rather than obsessive-compulsive personality disorder (OCPD). Clients with OCPD may appear rigid and controlling but do not typically demonstrate a profound lack of empathy.
B. Fear of abandonment: This is a hallmark feature of borderline personality disorder, not OCPD. Clients with OCPD usually struggle with control, orderliness, and perfectionism rather than intense fears of being abandoned.
C. Distrust of others: Distrust is more indicative of paranoid personality disorder. While OCPD clients may be critical or controlling, pervasive suspicion and mistrust are not primary features.
D. Focus on perfectionism: A hallmark manifestation of OCPD is a preoccupation with order, rules, and perfectionism. Clients may become inflexible, excessively devoted to work, and unable to delegate tasks due to their high standards, making this the expected finding.
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