While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room.
What should be the nurse’s initial action?

Choice A rationale

The unlicensed assistive personnel (UAP) is providing care to a client with influenza, a respiratory illness that can be transmitted through droplets when the client coughs or sneezes. Therefore, it is crucial for the UAP to wear a face mask while in close contact with the client to prevent the transmission of the virus. This is in line with the standard precautions for infection control, which recommend the use of personal protective equipment (PPE) such as gloves, gowns, and masks when providing care to clients with infectious diseases.
Choice B rationale
Reassigning the UAP to another client and assuming full care of the client is not the most appropriate action in this situation. While it is the nurse’s responsibility to ensure that the UAP is competent and understands the care needs of the client, it is not necessary to reassign the UAP unless there are specific concerns about their ability to provide safe and effective care.
Choice C rationale
While it is important for the UAP to alert the nurse of any changes in the client’s respiratory status, this is not the most immediate action that the nurse should take in this situation. The priority is to ensure that the UAP is wearing appropriate PPE to prevent the transmission of influenza.
Choice D rationale
A fitted respirator mask is typically used when caring for clients with airborne diseases, such as tuberculosis. Influenza is primarily spread through droplets, so a regular face mask is usually sufficient for protection.

Choice A rationale
Mixing the dextrose in a 50 mL piggyback for a total volume of 100 mL is not the best method for administering the medication. This would dilute the dextrose, potentially reducing its effectiveness.
Choice B rationale
Diluting the dextrose in one liter of 0.9% normal saline solution is not the best method for administering the medication. This would significantly dilute the dextrose, potentially reducing its effectiveness.
Choice C rationale
Asking the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution is not the best method for administering the medication. This would not provide the immediate glucose boost needed to counteract insulin shock.
Choice D rationale

Pushing the undiluted dextrose slowly through the currently infusing IV is the best method for administering the medication. This allows for rapid administration of a concentrated glucose solution, which is necessary to quickly raise blood glucose levels in a patient experiencing insulin shock.