A nurse would expect to administer which of the following medications to a client who is escalating to the point of a possible assault?

 

Choice A Reason:

It is extremely important to maintain professional boundaries with clients.

Maintaining professional boundaries is crucial in nursing to ensure a therapeutic and trusting relationship between the nurse and the client. Crossing these boundaries can lead to ethical issues and compromise the care provided. In this scenario, the nurse allowed personal relationships to influence professional behavior, which is inappropriate and can undermine the client’s trust and the integrity of the nurse-client relationship.

Choice B Reason:

Countertransference may have been a factor in your actions with this client.

Countertransference occurs when a nurse’s personal feelings and experiences influence their professional interactions with a client. In this case, the nurse’s familiarity with the client as a childhood friend of a sibling may have led to biased actions, such as allowing the use of a personal mobile device and sharing confidential information. Recognizing and managing countertransference is essential to maintain objectivity and provide unbiased care.

Choice C Reason:

It would have been better if you called your sibling instead of texting.

This statement is not relevant to the primary issues at hand. Whether the nurse called or texted their sibling does not change the fact that sharing the client’s hospitalization status was a breach of confidentiality. The focus should be on the inappropriate disclosure of protected health information, not the method of communication.

Choice D Reason:

Policies can be amended for clients who are admitted voluntarily, not involuntarily.

This statement is incorrect. Policies regarding the use of personal mobile devices and confidentiality apply to all clients, regardless of whether they are admitted voluntarily or involuntarily. The nurse’s actions violated these policies, and the distinction between voluntary and involuntary admission does not justify the breach.

Choice E Reason:

You have violated HIPAA regulations by notifying your sibling of the client’s admission.

This is the correct response. The nurse violated HIPAA regulations by disclosing the client’s hospitalization status to their sibling without the client’s consent. HIPAA protects the privacy of individuals’ health information, and unauthorized disclosure is a serious violation that can result in legal and professional consequences.

Choice A Reason:

Lorazepam is a benzodiazepine commonly used to manage acute agitation and anxiety. It works by enhancing the effect of the neurotransmitter GABA, which has a calming effect on the brain. Lorazepam is often administered in emergency situations to quickly reduce agitation and prevent escalation to violence. Its rapid onset of action makes it an ideal choice for managing acute episodes of agitation and potential assault.

Choice B Reason:

Valproic acid is an anticonvulsant and mood stabilizer used primarily for the treatment of epilepsy and bipolar disorder. While it can help manage mood swings and prevent manic episodes, it is not typically used for the immediate management of acute agitation or aggression. Its effects are not rapid enough to address an escalating situation effectively.

Choice C Reason:

Bupropion is an atypical antidepressant used to treat major depressive disorder and to support smoking cessation. It works by inhibiting the reuptake of norepinephrine and dopamine, but it does not have the sedative properties needed to manage acute agitation or aggression. Therefore, it is not suitable for immediate intervention in a potentially violent situation.

Choice D Reason:

Sertraline is a selective serotonin reuptake inhibitor (SSRI) used to treat depression, anxiety disorders, and other mood disorders. While it is effective for long-term management of anxiety and depression, it does not have the rapid calming effects required for managing acute agitation or potential assault. SSRIs generally take several weeks to achieve their full therapeutic effect.