The client is a male who states his wife complains that his snoring awakens her at night.
The spouse is present.
To obtain further data, the nurse asks the spouse:

Choice A rationale

Refusing to administer the medication without further investigation could jeopardize the client's timely treatment. While safety is paramount, the nurse's initial action should be to gather more information rather than outright refusal, which could delay necessary care.

Choice B rationale

Administering a medication that appears to be abnormally high without verifying the order is unsafe and could lead to serious adverse effects for the client. Nurses have a professional responsibility to question orders that seem incorrect or potentially harmful.

Choice C rationale

Documenting concerns is an important step in the process, but it is not the best *next* action. While documentation is crucial for legal and communication purposes, directly addressing the potentially erroneous order with the prescriber takes precedence to ensure patient safety.

Choice D rationale

Querying the physician about the order is the most appropriate immediate action. This allows the nurse to clarify the dosage, route, and rationale for the high dose. It opens a dialogue with the prescriber to confirm the order's accuracy or identify a potential error, directly addressing the safety concern.

Choice A rationale

Locked-in syndrome is a rare neurological disorder characterized by complete paralysis of all voluntary muscles except for those that control eye movement. The client's reported symptoms of drowsiness, irritability, and decreased attention span do not align with the typical presentation of locked-in syndrome, where cognitive function remains largely intact.

Choice B rationale

Sensory deprivation occurs when there is a reduction in sensory input, leading to various psychological and physiological effects. The client's recent loss of regular visits from her daughter and family, coupled with the reported symptoms of drowsiness, excessive sleeping, decreased attention span, irritability, and signs of depression, strongly suggest sensory deprivation as a contributing factor due to reduced social interaction and stimulation.

Choice C rationale

Residential psychosis is not a recognized or well-defined psychological or psychiatric term. Therefore, it is not an appropriate diagnosis for the client's symptoms.

Choice D rationale

Disturbed sensory perception involves alterations in the processing of sensory stimuli, such as hallucinations or delusions. While the client exhibits changes in her mental state, the reported symptoms are more indicative of a lack of sensory input and social interaction rather than distorted sensory processing.