A patient is prescribed morphine sulfate 5 mg IV every 4 hours as needed for a pain level greater than 7 on a scale of 0-10. Morphine is available in 8 mg/mL vials. How many mL will the nurse give for the correct dose?

Round to the nearest hundredth. Use a preceding zero if necessary. Do not use trailing zeros.

Choice A Reason:

Ask open-ended questions.

While asking open-ended questions can be useful in many therapeutic settings, it may not be the best approach when dealing with delusional clients. Open-ended questions can sometimes lead to more elaborate delusional thinking and may not help in grounding the client in reality. Instead, focusing on the present moment and concrete reality can be more effective in managing delusions.

Choice B Reason:

Focus on what is happening in the here and now.

This is the correct response. Focusing on the present moment helps to ground the client in reality and can reduce the intensity of delusional thoughts. By directing the client’s attention to their immediate environment and current activities, the nurse can help the client stay connected to reality and reduce the impact of their delusions.

Choice C Reason:

Assume knowledge of what is meant when the client talks about “they.”

Assuming knowledge of what the client means when they refer to “they” can reinforce delusional thinking. It is important for the nurse to clarify and understand the client’s perspective without validating the delusion. This approach helps maintain a therapeutic relationship while not reinforcing false beliefs.

Choice D Reason:

Limit contact to one or two short interactions daily.

Limiting contact to one or two short interactions daily is not an effective strategy for managing delusions. Clients with delusions often need consistent and supportive interactions to help them stay grounded in reality. Frequent, brief interactions can provide the necessary support and reassurance without overwhelming the client.

The correct answer is c.

Choice A Reason:

The statement “I am glad I’m getting out of here. I shouldn’t be here anyway.” indicates a lack of insight into the need for treatment and does not demonstrate readiness for discharge. Clients who are ready for discharge typically acknowledge their condition and the importance of ongoing care. This statement suggests denial or minimization of the issues that led to hospitalization, which can be a barrier to successful discharge and continued recovery1.

Choice B Reason:

The statement “I know I’m ready to go. I’ve got everything under control.” can be misleading. While it may seem positive, it lacks specific details about the client’s discharge plan and follow-up care. Readiness for discharge involves more than just feeling ready; it requires a concrete plan for managing medications, follow-up appointments, and support systems. Without these details, the statement does not fully indicate readiness for discharge.

Choice C Reason:

The statement “I have a list of my medications and have made an appointment with my doctor.” is correct. This statement demonstrates that the client has a clear understanding of their medication regimen and has taken proactive steps to ensure continuity of care after discharge. Having a follow-up appointment scheduled is a critical component of discharge planning, as it helps ensure that the client will continue to receive necessary support and monitoring. This level of preparation indicates that the client is ready for discharge.

Choice D Reason:

The statement “I just can’t get rid of these thoughts about dying.” is a serious concern and indicates that the client is not ready for discharge. Persistent thoughts of dying or suicidal ideation require immediate attention and intervention. Discharging a client with these thoughts would be unsafe and could lead to severe consequences. The client needs further evaluation and treatment to address these thoughts before being considered for discharge.