A nurse in the Emergency Department is caring for a client with symptoms of depression and admits to thoughts of self-harm with a plan. The client has a history of borderline personality disorder, depression, and substance abuse. Which of the following is the priority action by the nurse?

Choice A rationale:

Monitoring vital signs throughout the day is essential for a client experiencing mania, but it is not a specific intervention related to managing the manic state. Mania is associated with high energy levels and hyperactivity, which can affect vital signs. However, this intervention does not directly address the core symptoms of mania.

Choice B rationale:

Maintaining an environment with low stimuli is crucial for managing a client experiencing mania. Manic individuals are often highly sensitive to external stimuli, and a low-stimulation environment helps reduce agitation and potential exacerbation of manic behaviors.

Choice C rationale:

Discouraging the client from taking a nap during the day is not a suitable intervention for managing mania. Sleep disturbances are common during manic episodes, and attempting to restrict daytime naps might increase restlessness and agitation.

Choice D rationale:

Weighing the client every 3 to 4 days is not a specific intervention for managing mania. Weight monitoring might be relevant in certain contexts, such as if the client's medication regimen is associated with weight changes, but it does not directly address the manifestations of mania.

Choice E rationale:

Offering nutritional foods to the client every 2 hours is an important intervention for managing mania. Manic individuals often engage in impulsive behaviors, including neglecting self-care such as eating. Providing regular and nutritious meals helps stabilize blood sugar levels and supports the body's energy demands during this hyperactive phase.

Choice A rationale:

The client taking an overdose of the medication is unlikely to be the cause of the symptoms. Disulfiram (Antabuse) is a medication used to treat alcohol dependence by causing adverse effects when alcohol is consumed. However, an overdose would not result in severe nausea and vomiting as described.

Choice B rationale:

Experiencing common side effects of the medication is a possibility, but severe nausea and vomiting are not typical side effects of disulfiram. The medication's primary purpose is to induce unpleasant effects when alcohol is consumed, not to cause severe gastrointestinal symptoms.

Choice C rationale:

Demonstrating an allergic response to the medication could potentially cause various symptoms, but severe nausea and vomiting are not commonly associated with allergies to disulfiram. Allergic reactions often manifest as skin rashes, itching, and respiratory symptoms, which are not described in this scenario.

Choice D rationale:

The correct choice. Disulfiram works by inhibiting alcohol metabolism, leading to the accumulation of acetaldehyde, a toxic substance, when alcohol is consumed. This buildup of acetaldehyde results in unpleasant symptoms like severe nausea, vomiting, headache, and flushing. Since the client has recently started taking disulfiram and reports experiencing severe nausea and vomiting after discontinuing the medication, it is most likely that the client consumed alcohol while taking the medication, triggering the adverse reaction.