A nurse is preparing to administer haloperidol 7 mg lIM to a client who is severely agitated. Available is haloperidol injection 5 mg/mL. How manymL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

The findings that require follow-up are:

Client brought to the ED by police after being found wandering on the street. This indicates a potential safety issue and could suggest confusion or other cognitive impairment.

Client able to provide identity to police, but not able to identify place or time. This could indicate confusion or disorientation, which requires further assessment.

Client confused and agitated. Confusion and agitation can be symptoms of many conditions, including infection, intoxication, or neurological issues.

Appearance is disheveled. This could suggest self-neglect or other social issues that need addressing.

Mucous membranes dry. Dry mucous membranes can be a sign of dehydration, which may require treatment.

During assessment, client states, “Can you ask that person to leave my room?” Client is pointing to an empty chair. This could suggest hallucinations or delusions, which require further mental health assessment.

Temperature: 38.6° C (101.5° F). This is a fever and could indicate an infection or other medical condition.

Heart rate: 104/min. This is a high heart rate (tachycardia) and could be due to fever, dehydration, stress, or other conditions.

Blood pressure: 158/96 mm Hg. This is high blood pressure (hypertension) and could be due to a variety of conditions, including stress, kidney disease, or cardiovascular disease.

The other findings (f, j, l) are within normal limits and do not require immediate follow-up, but should continue to be monitored. Please consult with a healthcare professional for a comprehensive assessment.

Choice A Reason:
This response is open-ended and encourages the client to express their feelings and thoughts. It shows empathy and allows the nurse to gather more information about the client's emotional state. Open-ended questions are crucial in therapeutic communication as they help build rapport and trust, which are essential in managing clients with major depressive disorder. According to nursing guidelines, assessing the client's feelings and thoughts is a primary step in understanding their mental health status and planning appropriate interventions.

Choice B Reason:
Asking "Why did you feel like giving away your belongings?" might come across as judgmental or confrontational. It could make the client feel defensive or misunderstood. In therapeutic communication, it's important to avoid "why" questions as they can imply criticism and may not encourage the client to open up. Instead, focusing on the client's feelings and experiences is more effective in understanding their condition.

Choice C Reason:
Saying "Everyone feels a little down sometimes" minimizes the client's feelings and can be perceived as dismissive. Clients with major depressive disorder often feel isolated and misunderstood, and such a response could exacerbate these feelings. It's important for nurses to validate the client's emotions and provide support rather than downplaying their experiences.

Choice D Reason:
While suggesting a support group can be helpful, it is not the most immediate or appropriate response in this context. The client has expressed a significant behavior (giving away personal belongings) that could indicate suicidal ideation or severe depression. The nurse's priority should be to assess the client's current emotional state and risk factors before suggesting long-term solutions like support groups.