Level: Clinical
Difficulty: Medium
Subtopic: Mood disorders
NCLEX: A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for major depressive symptoms. Asse…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for major depressive symptoms. Assessment data include the client reports hearing voices telling them to hurt themselves. Before a medication-related action, what must the nurse verify?
Question
A. Administer on schedule even when the client is unarousable.
B. Skip allergy checks if the drug was given previously without reaction.
C. Delegate medication judgment to UAP to save time.
D. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
B. Skip allergy checks if the drug was given previously without reaction.
C. Delegate medication judgment to UAP to save time.
D. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
Rationale
Correct answer: D. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
Rationale: Medication safety requires full rights verification and monitoring; shortcuts increase error risk on the NCLEX and at the bedside.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Medication safety requires full rights verification and monitoring; shortcuts increase error risk on the NCLEX and at the bedside.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.