Psychiatric Medications Q 20
Tony refuses his evening dose of Haloperidol (Haldol), then becomes extremely agitated in the dayroom while other clients are watching television. He begins cursing and throwing furniture. Nurse Oliver first action is to:
A. Check the client’s medical record for an order for an as-needed I.M. dose of medication for agitation.
B. Place the client in full leather restraints.
C. Call the attending physician and report the behavior.
D. Remove all other clients from the dayroom.
Correct Answer: D. Remove all other clients from the dayroom.
The nurse’s first priority is to consider the safety of the clients in the therapeutic setting. Modify the environment. Decrease noise and distractions, or relocate. Check yourself. Do not raise your voice, show alarm or offense, or corner, crowd, restrain, criticize, ignore or argue with the person. Take care not to make sudden movements out of the person’s view.
Option A: Listen to the frustration. Find out what may be causing the agitation, and try to understand. Provide reassurance. Use calming phrases such as: “You’re safe here;” “I’m sorry that you are upset;” and “I will stay until you feel better.” Let the person know you are there.
Option B: See the client’s primary care physician to rule out any physical causes or medication-related side effects. Utilize safety measures to protect clients or others, if the client believes they need to protect themselves against a specific person. Precautions are needed. During an acute phase, a client’s delusional thinking might dictate to them that they might have to hurt others or self in order to be safe. External controls might be needed.
Option C: Do not touch the client; use gestures carefully. Suspicious clients might misinterpret touch as either aggressive or sexual in nature and might interpret it as a threatening gesture. People who are psychotic need a lot of personal space. If nursing interventions (quiet environment and firm limit setting) and chemical restraints (tranquilizers–e.g., haloperidol [Haldol]) have not helped dampen escalating manic behaviors, then seclusion might be warranted.