When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take?
Explain to the client that the dosage has been changed.
Withhold the medication until the dosage can be confirmed.
Inform him that he may refuse the medication and document whether or not he takes it.
Tell him to take the medication then verify the dosage at the next healthcare team meeting.
The Correct Answer is B
Choice A reason: Explaining to the client that the dosage has been changed is not a safe action because it may not be true. The nurse should not assume that the prescribed dosage is correct or different from the previous one without verifying it with the healthcare provider or the medication record.
Choice C reason: Informing him that he may refuse the medication and documenting whether or not he takes it is not a responsible action because it does not address the issue of dosage discrepancy. The nurse should respect the client's right to refuse medication, but should also educate him about the benefits and risks of taking or not taking it. The nurse should also try to resolve any barriers or concerns that may affect the client's adherence to medication.
Choice D reason: Telling him to take the medication then verifying the dosage at the next healthcare team meeting is not a timely action because it may cause harm or complications to the client. The nurse should not administer any medication without checking its accuracy and appropriateness for the client. The nurse should also report and document any medication incidents as soon as possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Yellow-tinged sputum is not a serious adverse effect of linezolid. It may indicate an infection or inflammation in the respiratory tract, but it does not require immediate attention from the health care provider.
Choice B: Nausea and headache are common side effects of linezolid. They are usually mild and self-limiting, and they can be managed with supportive measures such as hydration, rest, and analgesics.
Choice C: Watery diarrhea is a sign of pseudomembranous colitis, a potentially life-threatening complication of linezolid. It is caused by an overgrowth of Clostridium difficile bacteria in the colon, which produce toxins that damage the intestinal mucosa. It can lead to dehydration, electrolyte imbalance, sepsis, and perforation. The nurse should report this finding to the health care provider immediately and stop the linezolid infusion.
Choice D: Increased fatigue is not a specific or serious adverse effect of linezolid. It may be related to the underlying infection, anemia, or other factors. It does not require urgent intervention from the health care provider.
Correct Answer is D
Explanation
Choice D is correct because allowing time for the behavior and then redirecting the client to other activities is an effective intervention for a client with OCD who is repeatedly washing the top of the same table. OCD is a disorder characterized by recurrent and intrusive thoughts (obsessions) and repetitive and ritualistic behaviors (compulsions) that cause distress and impairment. The nurse should not interfere with or criticize the client's compulsions, as this can increase anxiety and resistance. The nurse should instead set limits on the time and place for the compulsions and gradually reduce them by offering alternative coping strategies or distractions.
Choice A is incorrect because encouraging the client to be calm and relax for a while is not an effective intervention for a client with OCD who is repeatedly washing the top of the same table. The client may not be able to relax or stop their compulsions, as they are driven by irrational fears or beliefs that are difficult to control. The nurse should not minimize or dismiss the client's feelings, as this can make them feel misunderstood or invalidated.
Choice B is incorrect because teaching the client thought-stopping techniques and how to refocus behaviors is not an effective intervention for a client with OCD who is repeatedly washing the top of the same table. Thought-stopping techniques are cognitive strategies that aim to interrupt or replace negative or unwanted thoughts with positive or neutral ones. However, these techniques may not work for clients with OCD, as their obsessions are often persistent and resistant to change. The nurse should not attempt to teach new skills or challenge the client's thoughts during an acute episode of compulsion, as this can increase anxiety and frustration.
Choice C is incorrect because assisting the client to identify stimuli that precipitate the activity is not an effective intervention for a client with OCD who is repeatedly washing the top of the same table. The client may not be able to identify or avoid the triggers that cause their compulsions, as they are often internal or irrational. The nurse should not focus on finding the cause or meaning of the compulsions, as this can reinforce their significance or validity.
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