A nurse working in a community health center is speaking with a client who has a serious mental illness. The client states that they are unable to find employment and they do not understand why. Which of the following questions should the nurse ask? (Select all that apply.)

Rationale:

A. The medication administration record is important for verifying the order but should be used in conjunction with the patient’s identification.

B. The order sheet provides the details of the blood product to be administered but is not the primary source for verifying patient identity.

C. The chart includes medical history and orders but does not provide direct patient identification for blood administration.

D. The identification wristband is the primary and most direct method for verifying the patient’s identity to ensure that the correct blood product is administered to the correct patient.

Rationale:

A. Stage 2 (moderate) of alcohol withdrawal involves symptoms such as increased blood pressure and heart rate, mild confusion, and tremors, but does not typically include hallucinations or severe agitation.

B. Stage 3 (severe) alcohol withdrawal includes severe symptoms such as hallucinations (e.g., seeing spiders), severe agitation, and possible delirium tremens, which are consistent with the client's manifestations.

C. Stage 1 (mild) symptoms generally include mild anxiety and tremors but do not include hallucinations or significant changes in mental status.

D. The client’s manifestations indicate severe withdrawal symptoms, not just a general description.