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?

The correct answer is choicea. Carry on with surgical preparation of the client without a signed informed consent.

Choice A rationale:

In emergency situations where immediate surgery is required to save a patient’s life and no family members are available, the doctrine of presumed consent applies.This means that healthcare providers can proceed with necessary treatment without a signed informed consent to prevent serious harm or death.

Choice B rationale:

Asking the man’s friend to sign the informed consent is not appropriate because friends are not legally authorized to provide consent for medical procedures unless they have legal documentation proving their authority.

Choice C rationale:

Notifying the unit manager for an emergency court order would delay the necessary surgery, which could be detrimental to the patient’s health. In emergencies, immediate action is required, and waiting for a court order is not feasible.

Choice D rationale:

Continuing to provide life support while searching for a guardian would also delay the necessary surgery. In life-threatening situations, immediate surgical intervention is prioritized over finding a legal guardian.

Choice A rationale:

The client will have no signs of infection in the wound by day 7. Rationale: This outcome is appropriate because it sets a specific timeframe (day 7) for assessing the absence of infection in the wound. It provides a clear and measurable criterion for evaluating the effectiveness of the wound care plan.

Choice B rationale:

The client will report a pain level of 4/10 or less during dressing changes. Rationale: Pain management is an essential aspect of wound care. Setting a target pain level (4/10 or less) during dressing changes allows for monitoring and adjustment of pain management strategies, making it an appropriate outcome.

Choice C rationale:

The client will consume at least 75% of meals and snacks daily. Rationale: While nutrition is important for wound healing, this outcome is less directly related to the wound itself. Monitoring meal consumption is a valuable goal for overall health but may not be as closely tied to wound improvement as infection control, pain management, or wound care technique.

Choice D rationale:

The client will reposition self in bed every 2 hours with assistance. Rationale: Repositioning every 2 hours is an important preventive measure for pressure ulcer development. However, this choice may not be appropriate for this particular client if they are unable to reposition themselves, even with assistance. This outcome may not be achievable for all clients, and a more individualized goal may be necessary.

Choice E rationale:

The client will demonstrate proper wound care technique before discharge. Rationale: Ensuring that the client can perform proper wound care techniques independently or with minimal assistance is a crucial outcome. This ensures that the client can maintain wound hygiene and prevent complications after discharge.