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?

Based on the provided information, the following aspects of the assessment require urgent attention:

• The client’s request for sleeping medication: This indicates that she is having trouble sleeping, which can affect her recovery.
• The client’s distressing thoughts and memories about the house collapsing: This could be a sign of post-traumatic stress disorder (PTSD), which requires immediate attention and possibly referral to a mental health professional.
• The client’s statement about being in a “funk”: This could indicate depression or another mental health issue, which should be addressed promptly.
• The client’s preference for a quieter area of the unit: The noise by the nurses’ station is disturbing her rest, which is crucial for her recovery. Efforts should be made to accommodate her request if possible.

The correct answer is Choice D.

Choice D rationale: Keeping the nails trimmed short is crucial for a child with eczema because it minimizes the damage done when the child scratches their skin. Short nails reduce the risk of breaking the skin and causing infections or further irritation, which can exacerbate eczema symptoms. This preventive measure helps maintain the skin's integrity and reduces the risk of secondary infections.

Choice A rationale: Allowing the child to wear only 100% cotton clothing can help reduce skin irritation as cotton is a soft, breathable fabric. However, it is not as directly related to preventing the harm caused by scratching.

Choice B rationale: Applying baby lotion to the skin can help keep the skin moisturized, but it might not be sufficient for eczema management. A more intensive emollient or specific eczema treatment may be needed.

Choice C rationale: Bathing the child daily with bath oil can help moisturize the skin, but over-bathing can sometimes exacerbate eczema. It's important to use gentle, non-irritating bath products and to follow other guidelines, such as trimming nails.