A nurse is assisting with the care of a client who has experienced a divorce. Which of the following priority actions should the nurse take to promote secondary prevention?

Rationale:

A. A client who has narcissistic personality disorder and refuses to be alone in their room: Clients with narcissistic personality disorder typically display a need for admiration and may fear abandonment, but they are not at increased risk for physical injury.

B. A client who has social anxiety disorder and refuses to attend group therapy: Avoidance of social settings is a hallmark of social anxiety disorder. While it may lead to isolation, it does not place the client at increased risk for physical injury.

C. A client who has bipolar disorder and exhibits impulsive behaviour: Impulsivity during manic episodes in bipolar disorder can lead to high-risk activities such as reckless driving, substance use, or unsafe sexual behavior. These behaviors significantly elevate the client’s risk for accidental or intentional physical injury.

D. A client who has panic disorder and exhibits paresthesia: Paresthesia, such as tingling or numbness, is a common symptom during panic attacks but does not directly increase the risk for physical injury. While distressing, it typically resolves and is not associated with unsafe behaviors.

Rationale:

A. Search for the medication on the National Library of Medicine's MedlinePlus website: This action allows the nurse to independently access a reliable, evidence-based source to gather essential information about the medication, including its purpose, dosage, side effects, and precautions. It promotes safe and informed medication administration.

B. Ask the charge nurse to explain the purpose of the medication: While consulting experienced colleagues is acceptable, relying solely on another person without verifying the medication through a formal, credible source may lead to misinformation. Independent verification is a safer and more accountable approach.

C. Ask the client to state the indication for the medication: Clients may not always have accurate knowledge of their medications or may misunderstand the reason for their use. Relying on client input does not ensure medication safety and is not a substitute for clinical validation.

D. Allow the client to self-administer the prepared medication: Allowing a client to self-administer a medication that the nurse does not understand is unsafe and violates standards of medication administration. Nurses are responsible for knowing what they administer and ensuring it is appropriate for the client's condition.