The nurse observes an older adult patient who has been taking antipsychotic medications for 8 months. The patient is smacking her lips and blinking her eyes rapidly. The nurse also observes a protruding tongue. Which action by the nurse would be most appropriate?

Correct Answer: C

Rationale: Rationale: C is correct because the patient is exhibiting symptoms of tardive dyskinesia, a side effect of long-term antipsychotic use. It is crucial for the nurse to document these symptoms accurately to inform the healthcare team. A: Asking about side effects is important but doesn't address the specific symptoms observed. B: Contacting the physician for a different medication order may be necessary, but documenting the symptoms first is crucial. D: Tapering off the medication should only be done under medical supervision and after proper assessment, not based solely on observed symptoms.

Correct Answer: D

Rationale: The correct answer is D because when a client makes a written application to be admitted to a psychiatric facility, they typically retain the right to make decisions about their discharge unless they are determined to be a danger to themselves or others. This is in line with the principle of autonomy and informed consent in healthcare. Choices A is incorrect because civil rights are not necessarily all revoked upon admission. Choice B is incorrect as clients usually have the right to participate in discharge decisions. Choice C is incorrect as not all clients admitted to a psychiatric facility are necessarily deemed a danger to self or others.

Correct Answer: A

Rationale: The correct answer is A because Carolina should show genuine interest in the patient's decision and willingness to learn more about the therapy app. This approach demonstrates empathy, openness to new technologies, and a collaborative attitude. It also allows Carolina to explore the app's features, efficacy, and potential benefits for the patient's treatment. By engaging with the patient in this way, Carolina can better understand the patient's perspective and tailor her approach accordingly. Choices B, C, and D are incorrect because they either dismiss the patient's choice outright (B), express reluctance without further exploration (C), or come off as confrontational (D). These responses may alienate the patient, hinder the therapeutic relationship, and impede progress. It's essential for Carolina to maintain a supportive and client-centered approach in addressing the patient's decision.

Correct Answer: C

Rationale: Rationale: C is correct because the patient is exhibiting symptoms of tardive dyskinesia, a side effect of long-term antipsychotic use. It is crucial for the nurse to document these symptoms accurately to inform the healthcare team. A: Asking about side effects is important but doesn't address the specific symptoms observed. B: Contacting the physician for a different medication order may be necessary, but documenting the symptoms first is crucial. D: Tapering off the medication should only be done under medical supervision and after proper assessment, not based solely on observed symptoms.

Correct Answer: C

Rationale: The correct answer is C: Low self-concept. Due to the patient's family history of alcoholism, they may have experienced emotional neglect or instability, leading to low self-esteem and self-concept issues. This can manifest in various ways, such as seeking validation from others or struggling with self-worth. Delusions (A) and paranoid delusions (B) are not directly associated with a family history of alcoholism. Extroversion (D) is a personality trait and not necessarily linked to the patient's family background.