Substance Abuse and Abuse Q 17
The manic client announces to everyone in the dayroom that a stripper is coming to perform this evening. When the nurse firmly states that this will not happen, the manic client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the nurse determines that the most appropriate action would be to:
A. With assistance, escort the manic client to her room and administer Haldol as prescribed if needed.
B. Tell the client that smoking privileges are revoked for 24 hours.
C. Orient the client to time, person, and place
D. Tell the client that the behavior is not appropriate.
Correct Answer: A. With assistance, escort the manic client to her room and administer Haldol as prescribed if needed.
The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to Haldol. Alert staff if a potential for seclusion appears imminent. Usual priority of interventions would be: firmly setting limits; chemical restraints (tranquilizers); and seclusions.
Option B: Option B may increase the agitation that already exists in this client. Remain neutral as possible; Do not argue with the client. The client can use inconsistencies and value judgments as justification for arguing and escalating mania. Maintain a consistent approach, employ consistent expectations, and provide a structured environment. Clear and consistent limits and expectations minimize the potential for the client’s manipulation of staff.
Option C: Orientation will not halt the behavior. Use a calm and firm approach. Provides structure and control for a client who is out of control. Use short, simple, and brief explanations or statements. Short attention span limits understanding to small pieces of information. Chart, in nurse’s notes, behaviors; interventions; what seemed to escalate agitation; what helped to calm agitation; when as-needed (PRN) medications were given and their effect; and what proved most helpful.
Option D: Telling the client that the behavior is not appropriate already has been attempted by the nurse. Decrease environmental stimuli (e.g., by providing a calming environment or assigning a private room); helps decrease escalation of anxiety and manic symptoms.