A male client who is admitted with bipolar disorder, and manic psychosis, is placed in seclusion after unsuccessful attempts to de-escalate him 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 intramuscularly STAT prior to seclusion.

Which intervention is most important for the nurse to implement immediately after seclusion?

c) Call the healthcare provider and clarify the prescription. Correct

This is the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage.

Calling the healthcare provider and clarifying the prescription is the safest and most effective way to prevent medication errors and ensure the child's safety. The PN should not administer the medication until they are sure that it is correct and appropriate for the child.

a) Tell the pharmacy to send an accurate child's dosage.

This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage.

Telling the pharmacy to send an accurate child's dosage is not appropriate, as it may cause confusion, delay, or conflict with the healthcare provider's orders. The PN should not assume that they know the correct dosage for the child without consulting with the healthcare provider.

b) Ask another nurse if adult dosages are ever given to children.

This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Asking another nurse if adult dosages are ever given to children is not helpful, as it may not provide accurate or reliable information.

The PN should not rely on another nurse's opinion or experience without verifying it with the healthcare provider.

d) Request verification of the prescription by the charge nurse.

This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Requesting verification of the prescription by the charge nurse is not necessary, as it may waste time and resources.

The PN should be able to communicate directly with the healthcare provider and clarify any doubts or concerns about the prescription.

Choice A rationale:

The client will have no signs of infection in the wound by day 7. Rationale: This outcome is appropriate because it sets a specific timeframe (day 7) for assessing the absence of infection in the wound. It provides a clear and measurable criterion for evaluating the effectiveness of the wound care plan.

Choice B rationale:

The client will report a pain level of 4/10 or less during dressing changes. Rationale: Pain management is an essential aspect of wound care. Setting a target pain level (4/10 or less) during dressing changes allows for monitoring and adjustment of pain management strategies, making it an appropriate outcome.

Choice C rationale:

The client will consume at least 75% of meals and snacks daily. Rationale: While nutrition is important for wound healing, this outcome is less directly related to the wound itself. Monitoring meal consumption is a valuable goal for overall health but may not be as closely tied to wound improvement as infection control, pain management, or wound care technique.

Choice D rationale:

The client will reposition self in bed every 2 hours with assistance. Rationale: Repositioning every 2 hours is an important preventive measure for pressure ulcer development. However, this choice may not be appropriate for this particular client if they are unable to reposition themselves, even with assistance. This outcome may not be achievable for all clients, and a more individualized goal may be necessary.

Choice E rationale:

The client will demonstrate proper wound care technique before discharge. Rationale: Ensuring that the client can perform proper wound care techniques independently or with minimal assistance is a crucial outcome. This ensures that the client can maintain wound hygiene and prevent complications after discharge.