A nurse on a mental health unit is admitting a client.

Exhibits

Select the 3 client findings the nurse should recognize as manifestations of water intoxication.

Rationale:

A. Ensure that each client has a living will on file prior to treatment: While advance directives are encouraged, clients have the right to choose whether to have one, and care cannot be delayed or denied if they do not.

B. Place copies of incident reports in clients' medical records: Incident reports are internal risk management tools and should not be placed in the medical record, as this could increase legal liability and compromise confidentiality.

C. Obtain personal professional liability insurance coverage: Having individual liability coverage provides additional protection beyond employer coverage, ensuring legal and financial support if malpractice claims arise.

D. Overestimate clients' acuity to prevent short staffing: Falsifying acuity levels is unethical and can result in disciplinary action or loss of license; staffing concerns should be addressed through proper administrative channels.

Rationale:

A. "I recommend that you take this medication as prescribed.": This response dismisses the client’s concern and does not address the possibility of a medication error. It can also undermine trust and ignores the need for verification before administration.

B. "I will call the pharmacist now to check on this medication.": This is the most appropriate response because it prioritizes client safety by verifying the medication before administration. It also acknowledges the client’s concern and involves a qualified resource for confirmation.

C. "Did the doctor discuss with you that there was a change in this medication?": While this could provide insight into changes in therapy, it delays immediate verification and does not address the need to confirm the medication’s accuracy before giving it.

D. "Do you know why this medication is being prescribed for you?": This may promote client education, but it does not address the immediate safety concern or the need to verify the medication before administration.