A nurse on the renal floor is caring for a patient with a history of bipolar disorder. The patient is being very combative and aggressive. When the nurse approached the patient with an insulin shot, the patient threw a chair at the nurse. After reporting the incident to the charge nurse and the doctor, the nurse receives orders to administer lorazepam 2 mg IM to the patient. Before attempting to administer the IM lorazepam, the nurse should do which of the following?


•A nurse who has been the target of a violent outburst by a patient should report the incident immediately to the charge nurse, security personnel, and the doctor.

•If the doctor orders an antipsychotic or sedative for the patient, the nurse should have the charge nurse and security personnel accompany them for safety when they approach the patient to administer the injection.

•The patient should never be given a syringe and needle to administer when the patient has been combative or violent.

•Even if a patient has been violent, it is not acceptable for nurses to physically restrain a patient to administer an injection in most hospitals. The patient still has the right to refuse treatment. If the patient refuses treatment in this situation, law enforcement may be involved to protect the nurse and other members of the healthcare team. (The exception to this is in a psychiatric emergency in which a patient is deemed dangerous or a danger to him or herself. In a Code situation, nurses may administer medication while a patient is restrained with an order).

Visit our website for other NCLEX topics now!