Day 1
1100: Client transferred from the emergency department to behavioral health. The client is experiencing an acute manic episode and was found wandering the street with bizarre behavior. The client is alert, oriented to place and time only. Bright and expansive affect. Speech is slightly pressured with a normal pitch. The speech is circumstantial. The client's appearance is disheveled. The thought process is disorganized, and the client denies any hallucinations, although grandiose delusions were noted. Impaired insight and judgment. Psychomotor agitation was present as the client paced in the room during the interview. The plan is to admit involuntarily and start valproic acid to stabilize mood.
Day 3
0915: Nursing reports that the client has refused all medications and only eats 5-10% of all meals. The client is alert and oriented to place only. Expansive affect. Speech is pressured with a high pitch. The speech is nonsensical and tangential. The client is dressed in normal hospital attire. The thought process is disorganized, with significant derailments. The client denies any hallucinations, although grandiose delusions were noted—severely impaired insight and judgment. Considerable psychomotor agitation was present as the client paced relentlessly in the room during the interview.
Day 1
Oral Temperature 97.8° F (36.6° C)
Pulse 82
Respiratory rate 18
Blood pressure 133/81 mm Hg
Pulse oximetry reading 98% on room air
Day 2
Oral Temperature 98.9° F (37.2° C)
Pulse 94
Respiratory rate 16
Blood pressure 127/71 mm Hg
Pulse oximetry reading 97% on room air
Day 3
Oral Temperature 99.5°F (37.5°C)
Pulse 104
Respiratory rate 18
Blood pressure 110/74 mm Hg
Pulse oximetry reading 96% on room air
Day 3
- discontinue oral valproic acid
- valproic acid intravenous piggy-back (IVPB) 15 mg/kg every 12 hours
- obtain previous psychiatric medical records from the most recent hospitalization
- obtain a complete blood count (CBC) and complete metabolic panel (CMP)
- 0.9% sodium chloride (normal saline) 1000 mL, IV, once
The nurse reviews all of the clinical data and prepares to act based on day three's findings
➢ Complete the sentence below from the list of options
The nurse should ****prioritize**** [obtaining the laboratory testing / administering the saline infusion / initiating the valproic acid infusion / retrieving the client's previous medical records] because of the client's [vital signs. / risk for liver injury. / affect and psychomotor agitation. / inability to recall their health history.]
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