A nurse is caring for a client in the emergency department (ED). The client comes to the ED via ambulance. The client has a history of bipolar disorder and is experiencing acute mania.
Select the 3 prescriptions that the nurse should anticipate for this client.
Administer 0.9% sodium chloride IV.
Administer IV flumazenil.
Prepare the client for intubation.
Begin chest compressions
Administer IV naloxone.
Administer activated charcoal.
Prepare the client for electroconvulsive therapy (ECT).
Correct Answer : A,E,G
The correct answer/s is Choice/s A, E, and G.
Choice A rationale: Administering 0.9% sodium chloride IV is a common practice in emergency departments to ensure the patient is well-hydrated. This is particularly important for patients experiencing acute mania, as they may have neglected their physical health, including hydration, during their manic episode.
Choice B rationale: Flumazenil is an antagonist for benzodiazepines and is typically used to reverse the sedative effects of benzodiazepines. It is not typically used in the treatment of bipolar disorder or acute mania.
Choice C rationale: Preparing the client for intubation is usually reserved for situations where the patient is unable to maintain their own airway or adequate ventilation. This is not typically necessary in cases of acute mania unless there are other complicating factors.
Choice D rationale: Beginning chest compressions is a response to cardiac arrest. There is no indication in the that the patient is experiencing cardiac arrest, so this would not be a typical anticipation for a patient experiencing acute mania.
Choice E rationale: Administering IV naloxone is done in cases of suspected opioid overdose. While it’s not directly related to treating acute mania, it’s possible that the patient could have comorbid substance use issues, given the high rate of comorbidity between bipolar disorder and substance use disorders.
Choice F rationale: Administering activated charcoal is done in cases of certain types of poisoning or drug overdose. It is not typically used in the treatment of bipolar disorder or acute mania.
Choice G rationale: Preparing the client for electroconvulsive therapy (ECT) could be an appropriate anticipation for a patient experiencing acute mania. ECT is considered a highly effective treatment for severe mania, particularly when other treatments have failed or when rapid stabilization is required.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
While a client's unwillingness to accept treatment can be a challenge, it does not, in and of itself, meet the criteria for involuntary hospitalization beyond the initial 72-hour hold.
Forced treatment without a clear and imminent risk of harm can violate a patient's autonomy and rights.
It's crucial for healthcare professionals to balance a patient's right to self-determination with the need to protect individuals from harm.
Choice B rationale:
A client's plan to move out of state, even if it's considered a disruptive decision, does not constitute grounds for involuntary hospitalization.
Individuals have the right to freedom of movement and to make choices about their life, even if those choices are perceived as unwise or problematic.
Choice C rationale:
This is the correct answer because it aligns with the fundamental principle of involuntary hospitalization: to protect individuals who pose a serious risk of harm to themselves or others due to a mental health condition.
This rationale is rooted in the ethical and legal obligation to prevent harm and ensure public safety.
Choice D rationale:
A client's dislike of a neighbor is not a valid reason for involuntary hospitalization. Personal opinions or feelings, even if negative, do not automatically translate into a risk of harm that would justify involuntary confinement.
Correct Answer is C
Explanation
Choice A rationale:
While assigning a client to a private room might seem like a way to protect their privacy and offer a calm environment, it could also create isolation and reduce opportunities for observation by staff. This could increase the risk of a subsequent suicide attempt without timely intervention.
It's essential to balance privacy with safety needs, and a private room might not always be the most appropriate choice for a client who has recently attempted suicide.
Choice B rationale:
Placing metal utensils on the client's meal tray could introduce potential weapons that could be used for self-harm. It's crucial to remove any objects that could be used for suicide attempts, including utensils, sharp objects, belts, cords, or medications.
Providing safe alternatives, such as plastic utensils, is essential to reduce the risk of harm.
Choice C rationale:
Inspecting the client's personal belongings is a critical safety measure to ensure they don't have access to items that could be used for self-harm. This includes checking for sharp objects, medications, ropes, belts, or other potential hazards.
Removing any such items is essential to create a safe environment and reduce the risk of further suicide attempts.
Choice D rationale:
Tucking bedcovers over the client's hands and arms might restrict their movement, but it doesn't address the underlying risk of suicide. It's not an effective method of preventing self-harm, and it could even cause discomfort or agitation to the client.
More direct and comprehensive safety measures, such as close observation and removal of potential hazards, are necessary.
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