A male client who is admitted with bipolar disorder, manic psychosis, is placed in seclusion after unsuccessful attempts to de-escalate him during a sudden mood swing from laughter to jumping and screaming threats while waving a plastic dinner knife.

The client is given haloperidol.

5 mg intramuscularly STAT prior to seclusion.

Which intervention is most important for the nurse to implement immediately after seclusion?

Choice A rationale:

Checking the femoral site for hematoma formation is the most appropriate action in response to the client's complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Checking for hematoma allows the nurse to assess for bleeding and take appropriate measures to manage it.

Choice B rationale:

Stimulating the client to take deep breaths is not the most immediate action needed in this situation. While deep breathing is important for respiratory function, the client's pain at the groin site requires immediate assessment to rule out complications.

Choice C rationale:

Evaluating the integrity of the IV insertion site is not the primary concern in this case. The client's pain is localized to the groin site, which is where the cardiac catheterization was performed. Checking for hematoma formation at this site takes precedence.

Choice D rationale:

Assessing distal lower extremity capillary refill is important for assessing peripheral perfusion, but it is not the most immediate action needed when a client complains of pain at a specific site, such as the right groin insertion site after a cardiac catheterization. Checking for hematoma and assessing for bleeding should come first.

Choice A rationale:

Reporting the finding to the healthcare provider is important when the client no longer responds to commands and exhibits a specific response to pain. However, it should not be the first action. The nurse's initial response should be to assess and document the client's neurological status and response to pain to provide accurate information to the healthcare provider.

Choice B rationale:

Documenting the purposeful response to pain is the correct initial action in this scenario. The client's response, which involves pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward, is known as decerebrate posturing. It is a specific neurological response to painful stimuli and may indicate a brain injury. Documenting this response is crucial for the client's medical record and helps the healthcare provider assess the severity of the neurological injury.

Choice C rationale:

Initiating seizure precautions immediately is not the first action to take in this scenario. While the client's response to pain may resemble posturing seen in seizures, it is more indicative of a neurological injury or dysfunction. Further assessment and evaluation are needed before implementing seizure precautions.

Choice D rationale:

Administering a prescribed PRN analgesic is not the first action to take when the client exhibits decerebrate posturing in response to pain. This response indicates a neurological issue or injury that requires assessment and evaluation. Administering pain medication without a clear understanding of the underlying cause may not be appropriate and could potentially mask important neurological signs.