A male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now.
How should the PN respond?
Explain that the healthcare provider probably prescribed a different medication while he is hospitalized.
Tell the client that he is probably confused since being hospitalized tends to disorient clients.
Tell the client that the PN will verify that the dispensed medication is the valid prescription.
Explain that the pharmacy often substitutes generic equivalents for more expensive brands.
The Correct Answer is C
Medication administration is a process that involves prescribing, dispensing, and giving medications to patients. It is a critical and complex task that requires accuracy, safety, and adherence to the rights of medication administration, such as the right patient, right drug, right dose, right route, right time, right documentation, and right response.
When a male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now, this may indicate a potential medication error or discrepancy. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. A medication discrepancy is any difference between the current and previous medication regimens of a patient.
The PN should respond to the client's concern by telling him that the PN will verify that the dispensed medication is the valid prescription. This means that the PN will check the medication label, the medication order, and the medication administration record (MAR) to confirm that the medication given to the client matches the one prescribed by the healthcare provider. The PN will also compare the dispensed medication with a drug reference guide or a picture of the medication to ensure that it is the correct drug and dosage form. The PN will also report any suspected errors or discrepancies to the healthcare provider or the pharmacy for clarification or correction.
Options A, B, and D are incorrect answers, as they do not reflect the appropriate or responsible actions for the PN to take when faced with a possible medication error or discrepancy.
Option A is incorrect because explaining that the healthcare provider probably prescribed a different medication while he is hospitalized is not true or helpful, as it does not verify or resolve the issue.
Option B is incorrect because telling the client that he is probably confused since being hospitalized tends to disorient clients is rude and dismissive, as it does not acknowledge or address the client's concern.
Option D is incorrect because explaining that the pharmacy often substitutes generic equivalents for more expensive brands is not accurate or relevant, as it does not verify or resolve the issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C
Choice A rationale: This question prematurely assumes the client is experiencing command hallucinations, which are auditory hallucinations instructing the individual to perform specific actions, often dangerous. Scientifically, this bypasses the essential diagnostic step of characterizing the hallucination type. Without understanding onset, frequency, and context, asking about obedience risks escalating paranoia or defensiveness. Psychiatric assessment requires chronological and phenomenological data before evaluating risk. Prematurely probing intent may compromise rapport and hinder accurate clinical evaluation.
Choice B rationale: While substance-induced psychosis is a differential diagnosis, asking about hallucinogen use before establishing the nature and onset of symptoms may be perceived as accusatory. Scientifically, the DSM-5 criteria for substance-induced psychotic disorder require temporal correlation between substance use and symptom onset. Without knowing when the voices began, this question lacks diagnostic precision. A thorough psychiatric history must precede substance screening to avoid bias and ensure accurate etiological classification of hallucinations.
Choice C rationale: Establishing the onset of auditory hallucinations is foundational in psychiatric assessment. Scientifically, the timeline helps differentiate between transient, substance-induced, and chronic psychotic disorders such as schizophrenia. Early onset may suggest prodromal schizophrenia, while abrupt onset could indicate delirium or drug-induced psychosis. Understanding duration also informs risk stratification and treatment planning. This question respects clinical sequencing, allowing the nurse to gather essential data before exploring content, belief, or behavioral response to hallucinations.
Choice D rationale: Exploring the client’s belief about the reality of voices is part of assessing insight, but it should follow initial characterization of the hallucinations. Scientifically, insight evaluation helps determine the severity of psychosis and guides treatment adherence predictions. However, asking this prematurely may confuse or distress the client. Insight is typically assessed after establishing symptom chronology, frequency, and impact. Premature probing of belief risks misinterpretation and may hinder therapeutic engagement in early assessment stages.
Correct Answer is A
Explanation
Choice A rationale:
Impaired physical mobility relative to muscle rigidity has the highest priority in the nursing care plan for a client diagnosed with Parkinson's disease. Parkinson's disease is characterized by motor symptoms such as muscle rigidity, bradykinesia, and postural instability. Impaired physical mobility can significantly impact a patient's ability to perform activities of daily living and maintain independence. Addressing this issue is crucial to enhance the patient's quality of life and prevent complications such as falls.
Choice B rationale:
While the risk for aspiration relative to muscle weakness is a valid concern in Parkinson's disease, impaired physical mobility takes precedence as it directly affects the patient's ability to move, ambulate, and perform daily activities. Addressing mobility issues is fundamental to maintaining overall functioning and independence.
Choice C rationale:
The risk for constipation relative to immobility is important to address, but it is not the highest priority. Impaired physical mobility can lead to multiple complications, including constipation. However, improving mobility should be the primary focus to prevent a wide range of issues associated with Parkinson's disease.
Choice D rationale:
Self-care deficit relative to motor disturbance is a concern in Parkinson's disease, but it is not the highest priority. Impaired physical mobility directly impacts a patient's ability to engage in self-care activities. By addressing mobility issues first, the nurse can facilitate the patient's ability to perform self-care tasks more independently in the long run.
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