The nurse in the Emergency Department (ED) assesses a 17-year-old patient with blue-tinged lips, slowed respirations, and pinpoint pupils. The patient has no response to painful stimuli. Which of the following should be the nurse’s priority action?

Choice A Reason: Encouraging the client to consume foods high in vitamin B1 (thiamine) is beneficial, but it may not be sufficient alone to prevent Korsakoff’s syndrome in individuals with alcohol use disorder. Thiamine is crucial for brain function, and its deficiency can lead to Wernicke-Korsakoff syndrome. However, due to malabsorption issues common in alcohol use disorder, dietary intake alone might not meet the necessary thiamine levels.

Choice B Reason: Implementing strict bed rest to conserve energy is not directly related to preventing Korsakoff’s syndrome. While rest is important for overall health, it does not address the thiamine deficiency that leads to this condition. Korsakoff’s syndrome is primarily caused by a lack of thiamine, and conserving energy does not mitigate this deficiency.

Choice C Reason: Restricting fluid intake to prevent water intoxication is not relevant to preventing Korsakoff’s syndrome. Water intoxication is a separate issue and does not address the thiamine deficiency that causes Korsakoff’s syndrome. Proper hydration is important, but it does not prevent the neurological damage associated with thiamine deficiency.

Choice D Reason: Administering thiamine supplements as prescribed is the most appropriate intervention to prevent Korsakoff’s syndrome. Thiamine supplementation is crucial for individuals with alcohol use disorder because their bodies often cannot absorb enough thiamine from food alone. Thiamine is essential for brain function, and its deficiency can lead to severe neurological damage. Administering supplements ensures that the client receives an adequate amount of this vital nutrient.

Choice A Reason: Is not responding to other clients on the unit.

While a lack of response to other clients can indicate social withdrawal and isolation, which are common in depressive episodes, it does not necessarily indicate an immediate risk to the client’s safety. This behavior is concerning but does not require the highest priority intervention compared to other behaviors that may indicate a risk of self-harm or suicidal ideation.

Choice B Reason: Is refusing to take their prescribed mood stabilizer.

Refusing medication is a significant concern as it can lead to worsening of symptoms and destabilization of the client’s condition. However, this behavior does not indicate an immediate risk to the client’s safety. The nurse should address this issue promptly, but it is not the highest priority compared to behaviors that suggest suicidal ideation.

Choice C Reason: Angrily argues with another client stating, “God is dead.”

This behavior indicates agitation and potential conflict with others, which can be problematic in a clinical setting. However, it does not directly suggest an immediate risk to the client’s safety. The nurse should intervene to de-escalate the situation and provide support, but this is not the highest priority compared to signs of suicidal ideation.

Choice D Reason: States, “There is no future when you feel so depressed.”

This statement is highly concerning as it indicates feelings of hopelessness and potential suicidal ideation. Expressions of hopelessness and statements about the future being bleak are significant risk factors for suicide. The nurse should prioritize this behavior for immediate intervention to assess the client’s risk of self-harm and provide appropriate support and safety measures.