A nurse is talking with a client who reports that they have started feeling anxious every time they have to leave their house. Which of the following responses should the nurse make?

Choice A Reason:

Time-critical medications should generally be given within a specific time frame, usually 30 minutes before or after the scheduled time. Waiting for 60 minutes may lead to suboptimal therapeutic effects or potential complications.

Choice B Reason:

Documentation should occur after medication administration to ensure accuracy. Administering the medication should be confirmed before recording it in the patient's chart.

Choice C Reason:

Correct identification of the patient is crucial to ensure that the medication is given to the right person. Using at least two patient identifiers (e.g., name and date of birth) is a common practice to enhance accuracy.

Choice D Reason:

This is a fundamental safety measure in medication administration. The nurse should check the medication against the medication administration record three times: when removing it from storage, when preparing it, and before administering it to the patient. This helps prevent medication errors.

Choice A Reason:

Client isolates themselves from their family and friends. Isolating oneself from family and friends is an indication that the client is experiencing a crisis. Social withdrawal and isolation can be common responses to severe anxiety or a crisis situation. It suggests that the client is having difficulty coping with their anxiety or the stressor, and they may benefit from intervention and support.

Choice B Reason:

Reporting intermittent depressed mood may be indicative of a mood disorder but does not necessarily indicate a crisis.

Choice C Reason:

Reporting a decreased appetite can be a symptom of anxiety, but it is not specific to a crisis situation.

Choice D Reason:

Expressing an inability to experience pleasure is a symptom often associated with depression but does not provide specific information about the presence of a crisis.