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?

Choice A rationale:

Assessment of tobacco use geared toward adolescents. Rationale: While assessing tobacco use is essential for promoting health in adolescents, the question is about developing a class about mental health and addressing the increase in suicides in the community. Assessing tobacco use is not directly related to this topic. Stress self-management techniques are more relevant.

Choice B rationale:

Exploration of stress self-management techniques. Rationale: This is the correct answer. Addressing stress and teaching adolescents self-management techniques is crucial in the context of mental health promotion and suicide prevention. Adolescents often face stressors, and providing them with effective strategies to manage stress can contribute to their overall well-being.

Choice C rationale:

Video with statistics showing trends in suicide rates. Rationale: While providing statistics about suicide rates can be informative, it may not be the most engaging or effective method for teaching adolescents about mental health and stress management. Interactive activities and skill-building exercises are often more beneficial.

Choice D rationale:

Handouts for local substance abuse treatment centers. Rationale: Providing handouts for substance abuse treatment centers

Choice A rationale:

Stopping the heparin infusion immediately is essential when the client's aPTT is significantly elevated (in this case, 120 seconds). A prolonged aPTT indicates a higher risk of bleeding, and discontinuing the heparin infusion is a crucial step in preventing further bleeding.

Choice B rationale:

Administering protamine sulfate is necessary when a client on heparin therapy experiences excessive bleeding or if the aPTT is significantly elevated. Protamine sulfate acts as a heparin antagonist and can reverse the anticoagulant effects of heparin.

Choice C rationale:

Notifying the healthcare provider of the significantly prolonged aPTT is essential because it may indicate a need for adjustments in the heparin dosage or therapy. The provider can determine the appropriate course of action based on the client's clinical condition.

Choice D rationale:

Drawing a prothrombin time (PT) and international normalized ratio (INR) level is not necessary in this situation. PT and INR are more relevant parameters when assessing clients on warfarin therapy, not heparin.

Choice E rationale:

Monitoring the client for signs and symptoms of bleeding is crucial when the aPTT is prolonged, as it indicates a higher risk of bleeding. This action allows for early detection and intervention to prevent complications.