A client with bipolar disorder, manic psychosis, is placed in seclusion after unsuccessful attempts by staff at deescalating the client during a sudden mood swing from laughter to jumping and screaming threats while waving a plastic dinner knife.
The client is given haloperidol 5 mg IM STAT prior to seclusion.
What is the most important intervention for the nurse to implement immediately after seclusion?

Choice A rationale

Serum albumin levels can be relevant in assessing nutritional status and the body’s ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage.

Choice B rationale

Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.

Choice C rationale

Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.

Choice D rationale

Neutrophil count is a key laboratory value to note when a client with a full-thickness burn has purulent drainage at the wound. An elevated neutrophil count can indicate an infection, which could be the cause of the purulent drainage.

Choice A rationale

While monitoring the respiratory rate is important in a patient receiving opioids like hydromorphone, it does not directly indicate whether the patient is receiving an equianalgesic dose of the medication.

Choice B rationale

Pain scale assessment is the most direct way to evaluate if the patient is receiving an equianalgesic dose of hydromorphone. Equianalgesic refers to a dose of one opioid that would provide the same level of pain relief as a given dose of another opioid. If the patient’s pain is well-controlled, it suggests that the dose of hydromorphone is equianalgesic to the dose of the previous opioid.

Choice C rationale

Monitoring blood pressure is important in a patient receiving opioids as these medications can cause hypotension. However, blood pressure does not directly indicate whether the patient is receiving an equianalgesic dose of hydromorphone.

Choice D rationale

While it’s important to monitor the level of consciousness in a patient receiving opioids as these medications can cause sedation, it does not directly indicate whether the patient is receiving an equianalgesic dose of hydromorphone.