A nurse is caring for a client who has a newly created colostomy. The client's partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?

Rationale:

• Client has initiated a daily exercise routine: This indicates self-motivation, structured routine, and engagement in positive coping behaviors, all of which are therapeutic goals in managing schizophrenia.
• Client utilizes deep breathing techniques as needed: Use of self-regulation techniques like deep breathing suggests the client is managing anxiety and stress proactively.
• Client has joined a local support group: Participation in social support groups improves social functioning and decreases isolation, a common issue in schizophrenia.
• Client has been reading books about their illness: Demonstrates insight, knowledge-seeking behavior, and a willingness to understand and manage the condition, which aligns with psychoeducation goals.
• Client participates in cognitive-behavioral therapy sessions with their mental health provider: Engagement in CBT is a strong indicator of therapeutic alliance and compliance with structured treatment plans aimed at cognitive restructuring and behavioral management.

Rationale for Incorrect Finding:

• Client reports spending most of their time alone in their apartment: Although some solitude is not unusual, spending most of the time alone may indicate ongoing social withdrawal, a negative symptom of schizophrenia, and a barrier to full community reintegration.
• Client reports drinking 4 to 5 cups of coffee each morning: Excessive caffeine can worsen anxiety, interfere with sleep, and interact with psychiatric medications, so this behavior does not align with optimal treatment outcomes.

Rationale:

A. Check the label of the medication twice prior to administration: Safe medication practice requires the nurse to check the medication label three times, when retrieving, preparing, and before administering to minimize the risk of medication errors.

B. Use two identifiers to verify the client's identity: Using two patient identifiers, such as name and date of birth, ensures the medication is given to the correct individual. This step is crucial for patient safety and is a core component of safe medication administration practices.

C. Document administration of the client's routine medications at the beginning of the shift: Medications should only be documented after they have been administered. Pre-charting medication administration can lead to errors if the medication is delayed, omitted, or refused.

D. Ensure the medication is administered within 3 hr of the scheduled time: Medications are typically required to be administered within 30 minutes to 1 hour of the scheduled time unless otherwise specified. A 3-hour window is too broad and may compromise therapeutic effectiveness.