A nurse is caring for an adolescent who states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms?

A. "Verify the medication three times with the medication administration record.": This is the best practice for ensuring the correct medication is administered. The nurse should verify the medication when removing it from storage, before preparing the medication, and at the bedside before giving it to the patient to ensure the right drug, dose, patient, time, and route.

B. "Administer time-critical medication 60 min before or after the scheduled time.": Time-critical medications should be administered within a specified window of 30 minutes before or after the scheduled time, not 60 minutes. Administering medication too early or late could compromise its effectiveness.

C. "Identify the client by using one identifier before giving the medication.": The correct approach is to use two identifiers (e.g., name and date of birth) to verify the client's identity, not just one. This reduces the risk of medication errors.

D. "Document medication administration prior to administering medication.": Documentation should occur after medication administration, not before, to ensure accurate recordkeeping of the event.

A. The client develops chest pain each time he talks about his partner is an indication of complicated grief. The client’s experience of intense, physical symptoms like chest pain when discussing their partner suggests that the grief process may not be progressing and could indicate unresolved or complicated grief.

B. The client keeps a framed picture of his partner on the wall is a normal expression of grief. Keeping a picture of a lost loved one is common and doesn’t necessarily indicate complicated grief. It can be part of the natural grieving process.

C. The client reports he has no interest in dating is not necessarily a sign of complicated grief. It's common for people grieving to not have an interest in dating or forming new romantic relationships immediately after the loss, but it does not suggest a problem unless the client expresses prolonged avoidance of all social interaction.

D. The client attends a grief support group twice each month is a positive coping mechanism. Attending support groups shows the client is actively engaging with the grieving process and seeking support, which is part of healthy adjustment after a loss.