A 70yearold client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see him every Wednesday. Let me out!"

Which of the following would be the most therapeutic response by the nurse?

A. Increase your fluid and fiber intake to prevent constipation – Risperidone, an atypical antipsychotic, can cause constipation due to its anticholinergic effects. Increasing fluid and fiber intake can help prevent this.
B. Have your blood pressure checked frequently for hypertension – Risperidone is more commonly associated with orthostatic hypotension, not hypertension.
C. Expect to have your blood checked weekly for serum electrolyte imbalances – Unlike clozapine, risperidone does not require frequent blood monitoring for electrolyte imbalances.
D. Increase caloric intake to prevent weight loss – Risperidone is more likely to cause weight gain rather than weight loss, so increasing caloric intake is unnecessary.

A. "I don't have a problem, I can quit when, where and how I want to." This statement reflects denial and overconfidence, which are common obstacles to recovery. It suggests a lack of recognition of the seriousness of the addiction.

B. "I am not going to let my family and friends know I have an addiction and give them this burden." This statement indicates a reluctance to seek support from loved ones, which can hinder the recovery process. Keeping the addiction, a secret can lead to isolation and make it more
challenging to maintain recovery.

C. "I will start Alcoholic Anonymous meetings in two weeks when I am settled after discharge." This statement shows proactive planning and willingness to engage in support groups, which can be a positive step towards recovery.

D. "I know I am an addict, and it will take hard work and a higher power to help me." This statement reflects self-awareness and a recognition of the effort required for recovery. The
mention of a higher power suggests a willingness to engage in a spiritual or faith based approach to recovery, which can be beneficial for some individuals.

E. "I don't know how I am going to get through this but will take it one day at a time with my family." This statement acknowledges the challenges ahead and expresses a willingness to take recovery one step at a time with the support of family. It reflects a realistic and hopeful approach to the recovery process.