A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of the following information should the nurse report to the occupational therapist?

Rationale for correct choices:

• Insert a large-bore IV catheter: A large-bore IV (18–20 gauge) is necessary to allow rapid administration of blood products and reduce hemolysis of red blood cells during transfusion. This ensures safe and effective delivery of the blood components.
• Witness the client signing a consent for transfusion: Informed consent is required before initiating a blood transfusion. The nurse ensures that the client understands the purpose, risks, and potential complications, and witnesses the signing to meet legal and ethical standards.
• Have a second nurse confirm the information on the blood lab: Verifying the blood type, crossmatch, and client identifiers with a second nurse reduces the risk of transfusion errors and ensures patient safety before starting the transfusion.

Rationale for incorrect choices:

• Explain to the client that transfusion reactions are not serious: Transfusion reactions can be serious, including hemolytic reactions, febrile reactions, or allergic responses. The nurse should educate the client on the potential risks and signs of a reaction rather than minimizing them.
• Flush the transfusion tubing with dextrose 5% in water: Blood products should only be administered with 0.9% sodium chloride (normal saline). Flushing with dextrose or other solutions can cause hemolysis and compromise the safety of the transfusion.

Rationale for correct choices:

• Mania: The client exhibits classic signs of mania, including decreased need for sleep, excessive energy, impulsive spending, grandiosity, pressured and disorganized speech, and poor self-care. These behaviors reflect a manic episode, often seen in bipolar disorder, which requires careful monitoring and intervention.
• Euphoric mood: The client demonstrates an abnormally elevated and joyous mood, along with inflated self-confidence and excessive sociability. This euphoric mood is a hallmark feature of mania and differentiates it from other psychiatric conditions such as depression or delirium.

Rationale for incorrect choices:

• Major depressive disorder: This disorder presents with persistent low mood, anhedonia, and decreased energy. The client displays the opposite symptoms, including hyperactivity, elevated mood, and impulsivity, making depression an unlikely diagnosis.
• Delirium: Delirium is characterized by an acute change in attention, confusion, and disorientation, often fluctuating throughout the day. While the client is disoriented to place, the presence of sustained elevated mood and hyperactivity supports mania rather than delirium.
• Panic disorder: Panic disorder involves sudden, intense episodes of fear with physical symptoms like palpitations, shortness of breath, and sweating. The client’s presentation is chronic and includes mood elevation and impulsive behaviors, which are inconsistent with panic disorder.
• Catatonia: Catatonia involves motor immobility, mutism, or extreme negativism. The client is highly active, with constant movement and pressured speech, which is the opposite of catatonic presentation.
• Anhedonia: Anhedonia refers to the inability to experience pleasure and is a symptom of depression. The client shows excessive pleasure-seeking behaviors, including socializing and impulsive spending, making anhedonia inconsistent with the current presentation.
• Hypervigilance: Hypervigilance involves heightened alertness and exaggerated startle response, often seen in anxiety or PTSD. The client’s primary features are elevated mood and impulsive behavior rather than persistent vigilance.
• Magical thinking: Magical thinking involves believing that one’s thoughts or actions can influence unrelated events. While the client reports hallucinations, there is no evidence of magical thinking as the hallucinations do not involve causative beliefs.
• Alogia: Alogia is a reduction in speech output, typically seen in schizophrenia or severe depression. The client’s speech is pressured, loud, and disorganized, which is opposite to alogia.