A client is admitted with bipolar disorder, manic psychosis. The client is placed in seclusion after unsuccessful attempts by staff at deescalating the client during a sudden mood swing from laughter to jumping and screaming threats while waving a plastic dinner knife. The client is given haloperidol 5 mg IM STAT prior to seclusion. Which intervention is most important for the nurse to implement immediately after seclusion?

Secure the room with padded walls and minimal furnishings.

Provide one-on-one observation at all times.

Release the client as soon as composure is regained.

Observe for extrapyramidal symptoms, such as dystonia.

Answer and Explanation

The Correct Answer is D

Rationale

A. While ensuring the room is secure and providing one-on-one observation are also important, the immediate concern after administering haloperidol is the potential for these side effects.

B. Continuous observation is crucial to monitor the client's behavior, mood, and safety while in seclusion. This allows the nurse to intervene promptly. However, monitoring should be specific

C. Seclusion is not intended as a punishment but as a therapeutic intervention to protect the client and others from harm during acute psychiatric episodes. The decision to release the client should be based on clinical assessment

D. Haloperidol is an antipsychotic medication that can cause extrapyramidal symptoms (EPS), including dystonia (muscle spasms). Monitoring for EPS is essential after administering haloperidol to ensure early detection and treatment, which may involve administering anticholinergic medications if EPS occurs.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C"]

Explanation

Rationale

A. High in sodium due to pickling, which is not suitable for someone with hypertension.

B. Recommended because fresh fruits are low in sodium and high in potassium and other nutrients beneficial for managing blood pressure.

C. Recommended because they are low in sodium and rich in potassium, fiber, and nutrients that support cardiovascular health.

D. Cottage cheese is high in sodium and should be avoided or consumed in moderation.

E. Generally high in sodium, which should be limited or avoided in the diet of someone with hypertension.

A. An adult with alcoholism, cirrhosis, and hepatic encephalopathy. B. An older adult who is scheduled for foot amputation due to diabetes complications. C. An adult who is one day postoperative for a laparoscopic cholecystectomy. D. An older client who is one day postoperative with a colostomy for colon cancer.

Correct Answer is C

Explanation

Rationale

A. This client may require complex care related to liver disease and alcoholism, likely exceeding the scope of practice for a PN.

B. While this client requires specialized wound care and diabetes management, the tasks involved may be appropriate for a PN under RN supervision.

C. This client's care typically involves routine postoperative monitoring and interventions that are suitable for a PN under RN supervision.

D. This client requires specialized ostomy care and postoperative monitoring, which can generally be managed by a PN under RN supervision.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

Correct Answer is ["B","C"]

Explanation

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Correct Answer is C

Explanation

Exhibits Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected.

A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse has reviewed the client's chart. Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that this client is dropdown due to dropdown

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?