Nurse Karim arrives for the day shift on the inpatient mental health unit. Nurse Kay provides the following shift report about the client in room 120:

Morning, I'm going to be providing you with a report on the client, Terry Jones. Terry previously presented to the emergency department 3 weeks ago, accompanied by police for risk of harm to self. He was assessed and discharged home with an outpatient consultation for depressive symptoms. He re-presented to the emergency department 3 days ago following self-harm. He was brought to emergency by ambulance when his mother found him unconscious in his home. He sustained a significant vascular injury to his external carotid artery, self-inflicted by a knife. He had emergency vascular surgery to repair his carotid artery and was admitted to ICU for recovery before being transferred to this unit. He is now displaying signs of a manic episode and has required physical and chemical restraint use in his first few days of admission for significant risk to self and to staff as he was thrashing and grabbing at the dressing on his neck. We have used olanzapine 10mg IM as a chemical restraint with good efficacy. He last had that administered 3 days ago. He has a history of hypertension and query alcohol use disorder.

He has been started on oral Olanzapine, due at 0800, and Lithium, given at 2000, to address the mania, and we've been starting to see some effect with reducing manic symptoms over the past few days. He is resistant to taking his medications, and at times it has required multiple re-approaches to have him comply. He has a wound on the right side of his neck, it is approximately 4 inches long. The wound is closed by stitches and has a pressure dressing applied that is being changed q12 hours and as needed. His first bloodwork for his lithium levels is due at 0800 today.

His mental status has been fluctuating. He is quite paranoid and holds some fixed delusions about a previous coworker trying to poison him. He is still experiencing some periods of significant agitation where he presents with pressured speech, alterations to thought content and process, and becomes uncooperative. As his agitation escalates, he begins to get violent with staff. During the course of his stay, three code whites have been called for violence directed towards nurses. He seems most triggered by large male staff, so we are trying to adapt his nursing assignment. He hasn't been eating or drinking much since he has been here, related to paranoia around his delusion. He also is resistant to engaging in personal care, one staff was able to get him to agree a few days ago to wash, and we've been able to help him change his clothes limited times. Let's go in.

You have completed your morning head-to-toe assessment with Terry. Review the assessment data collected here.

Medications:
- Olanzapine 10mg, once daily 0800, ORAL
- Atorvastatin 30mg, once daily 0800, ORAL
- Ramipril 10mg, once daily 0800, ORAL
- Lithium 800mg, once daily 2000, ORAL
- Olanzapine 10mg, IM, PRN q4 hours, for agitation
- Ibuprofen 400mg, ORAL, PRN q6 hours, for pain

Which medication order should you question? Based on your response, explain your rationale for questioning this medication order.

The Ibuprofen 400mg order should be questioned due to the increased bleeding risk associated with NSAIDs in a patient with a history of significant vascular injury and recent vascular surgery.

Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding, especially when given to a patient with a history of vessel injury and recent surgery.

Given that Mr. Jones sustained a significant vascular injury to his external carotid artery and required emergency vascular surgery to repair it, the use of ibuprofen could compromise his vascular repair, increase his risk of bleeding, and therefore should be questioned.

Additionally, patients with manic symptoms like Mr. Jones may not reliably communicate the intensity of their pain or the effects of the medication, which necessitates cautious use of any pain management interventions that could pose additional risks.