A nurse is planning care for a client who has chronic substance use disorder. Which of the following is the most therapeutic response to help the client cease alcohol consumption?
"Let me tell you how I struggled to stop drinking whiskey over the years, but finally succeeded."
"You have stopped drinking, haven't you?"
"The physician has ordered you to stop drinking all alcoholic beverages. Are you going to make us happy?"
"Let's work together on a plan that includes medication, group support, and counseling."
The Correct Answer is D
Rationale:
A. Sharing personal experiences can be supportive, but it may not be the most therapeutic or professional approach in this situation.
B. This question is leading and doesn't encourage an open dialogue. It may also induce guilt or defensiveness in the client.
C. This statement is authoritative and may come across as coercive, which can be counterproductive in encouraging the client to take responsibility for their recovery.
D. Collaborating with the client on a comprehensive plan that includes medication, group support, and counseling is a therapeutic approach that empowers the client to actively participate in their recovery, offering them the best chance of success.
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Correct Answer is D
Explanation
Rationale:
A. Seizures and tremors can occur with some antipsychotic medications but are not specifically indicative of tardive dyskinesia.
B. Hallucinations and delusions are symptoms of psychosis, not a side effect of anti-psychotic medications.
C. Nausea and vomiting can be side effects of anti-psychotic medications but are not characteristic of tardive dyskinesia.
D. Tardive dyskinesia is characterized by uncontrolled, repetitive movements, such as facial grimacing, tongue protrusion, and other involuntary movements.
Correct Answer is D
Explanation
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.