A 22-year-old male patient who has been increasingly paranoid and intrusive with peers begins throwing furniture around and threatens to kill anyone who comes near him. Even after being safely secluded in an isolation room, he continues yelling and begins banging his head against the door with force. The psychiatrist on call orders 2mg lorazepam and 10 mg haloperidol IM x1 time STAT. What is the appropriate nursing action?

Administer the medications immediately.

Explanation

•The nurse should administer the medications immediately to protect the patient from harm. The patient is at risk for giving himself a concussion if he is banging his head forcefully on the door, and in this situation, withholding this treatment would be negligent.

•If it were possible to talk to the patient without putting staff or other patients in danger of being injured, that would be attempted first, but this patient is too dangerous and is an immediate physical danger to himself.

•There are situations in which it is inappropriate to medicate a patient without their consent or to subdue them, but due to the risk of harm, this medication order is appropriate.

Incorrect options:

•Refusing to give the medication to a patient in this level of agitation and distress would be negligent.

•Checking to see if there is a PRN order for a lower dose to give could have been appropriate before the situation escalated, but now it would not be appropriate.

•Normally, the patient or his DPOA would have to consent to any pharmacologic treatment ahead of time, but in situations where a patient or other patients are in immediate physical danger, no consent is needed.

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