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. What action should the nurse take?

Correct Answer: B

Rationale: In this scenario, the correct action for the nurse to take is option B: withhold the medication until the dosage can be confirmed. This choice prioritizes patient safety by ensuring that the client receives the correct dosage of the prescribed medication, avoiding potential harm or adverse effects from an incorrect dosage. Option A is incorrect because administering a medication without verifying the dosage could lead to serious consequences for the client's health. Option C is also incorrect as it does not address the immediate need to confirm the correct dosage before administering the medication. Option D is not the best choice as it assumes the client is aware of the dosage change, which may not be the case. From an educational standpoint, this question highlights the importance of thorough medication administration practices in mental health nursing. Nurses must prioritize patient safety by verifying medication dosages before administration, especially when discrepancies or uncertainties arise. This situation also emphasizes the significance of clear communication with clients to ensure their understanding of prescribed treatments.

Correct Answer: D

Rationale: Alcohol abstinence is the most critical self-care measure for a client with early alcoholic cirrhosis. Continued alcohol consumption can lead to further liver damage and worsen the condition. Support group meetings may offer emotional support but do not address the root cause of the issue. While vitamin supplements and a nutritious diet are important for overall health, alcohol abstinence takes precedence in managing cirrhosis caused by alcohol consumption.

Correct Answer: A

Rationale: In individuals with bipolar disorder experiencing mania, impulsivity and poor judgment are common. Delaying business decisions until the mania subsides is crucial to prevent impulsive and potentially harmful financial choices. Choice B, identifying feelings associated with behaviors, may be important but does not directly address the immediate need to prevent risky financial decisions. Seeking legal counsel (Choice C) may be appropriate in some situations but is not the priority in managing acute mania. Describing why he feels fearful about finances (Choice D) is relevant for understanding emotions but does not address the immediate risk of impulsive financial actions during mania.

Correct Answer: A

Rationale: During a client assessment, noting and documenting nonverbal messages is important as it captures the full context of the client's communication. Nonverbal cues can often reveal underlying emotions or issues that may not be expressed verbally. Asking the client's husband to interpret the discrepancy (Choice B) may not be appropriate as it could potentially breach the client's privacy and trust. Ignoring nonverbal behavior (Choice C) can result in missing important cues that could impact the care provided. Integrating verbal and nonverbal messages (Choice D) is beneficial, but the initial step should be to pay close attention and document the nonverbal messages to fully understand the client's communication.

Correct Answer: D

Rationale: In this scenario, the most critical question for the RN to ask the client relates to hallucinations. Hallucinations, such as hearing sounds or voices others do not hear, are a hallmark symptom of schizophrenia. This inquiry is vital for assessing the presence of psychotic symptoms and the potential relapse of the client's condition. Choices A, B, and C, although important in assessing overall mental health, do not directly address the core symptomatology of schizophrenia or the potential impact of discontinuing antipsychotic medication abruptly.