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 A

Explanation

Rationale:

A. "Plan to take this medication with food.": Taking phenytoin with food can help reduce gastrointestinal irritation, such as nausea and upset stomach, which is a common side effect. Consistent administration with meals improves tolerability while maintaining therapeutic drug levels.

B. "Limit foods that contain folic acid while taking this medication.": Phenytoin can actually decrease folic acid absorption, and limiting folic acid intake could worsen potential deficiencies. Instead, monitoring and possibly supplementing folic acid may be recommended. Advising restriction could be harmful.

C. "Limit foods that contain vitamin D while taking this medication.": Phenytoin can reduce vitamin D metabolism, which may increase the risk of bone loss and fractures. Limiting vitamin D intake is not advised; rather, ensuring adequate vitamin D and calcium intake is important for older adults to maintain bone health.

D. "Plan to take this medication with antacids.": Antacids can interfere with the absorption of phenytoin, reducing its effectiveness. Taking phenytoin with antacids is contraindicated, and spacing the timing between antacids and phenytoin is necessary to maintain therapeutic levels.

A. A newborn who has forceful vomiting with feedings B. A newborn who has a heart rate of 160/min while crying C. A newborn who is 24 hr of age and has blood-tinged vaginal discharge D. A newborn who is 12 hr of age and has not voided

Correct Answer is A

Explanation

Rationale:

A. A newborn who has forceful vomiting with feedings: Forceful vomiting in a newborn may indicate pyloric stenosis, gastrointestinal obstruction, or other serious conditions that can quickly lead to dehydration and electrolyte imbalance. This is an urgent finding requiring immediate assessment to prevent rapid deterioration.

B. A newborn who has a heart rate of 160/min while crying: A heart rate of 160/min is within the expected range for a newborn (120–160/min) during activity or crying. While monitoring is necessary, this finding is not immediately concerning and does not require urgent intervention.

C. A newborn who is 24 hr of age and has blood-tinged vaginal discharge: A small amount of blood-tinged vaginal discharge (pseudomenstruation) is a normal hormonal response in female newborns due to maternal estrogen withdrawal. This is an expected finding and does not require urgent assessment.

D. A newborn who is 12 hr of age and has not voided: While monitoring urinary output is important, a newborn may normally not void within the first 12 hours of life. Assessment is needed, but it is not as urgent as forceful vomiting, which can quickly cause serious complications.

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