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","E","F"]

Explanation

A. Since the client is already on a fraction of inspired oxygen (FIO2) of 35% and has successfully weaned off the ventilator, increasing the FIO2 may not be necessary unless the client's oxygenation status deteriorates post-extubation.
B. As the client has successfully weaned off pressure support and is now at 0 cm H2O, the healthcare provider may consider transitioning to a different ventilator mode such as T-piece or CPAP (Continuous Positive Airway Pressure) to further assess the client's ability to breathe spontaneously without ventilator support.
C. Ice chips are typically offered to conscious patients to alleviate thirst or dry mouth. The client was previously intubated and may not be fully conscious or able to swallow safely immediately post- extubation.
D. Since the client has been weaned off pressure support successfully, there is no indication to set the ventilator to provide mandatory breaths. The focus is on assessing the client's ability to breathe spontaneously.
E. Even though the client has been weaned off the ventilator, it's important to ensure adequate oxygenation. Setting up supplemental oxygen delivery, such as via nasal cannula or face mask, can support the client's oxygen needs during the transition phase post-extubation.
F. Since the client has been successfully weaned to 0 cm H2O pressure support and the healthcare provider is evaluating the client, gathering supplies for potential extubation is appropriate. This includes ensuring all necessary equipment and supplies for a safe extubation procedure are readily available at the bedside.
G. Unless specifically indicated for other medical reasons not mentioned, there is no immediate need to place a nasogastric tube based on the information provided about the client's current condition post- weaning.

A. Monitor blood glucose level. B. Maintain strict intake and output. C. Assess warmth of extremities. D. Keep head of bed raised 45 degrees.

Correct Answer is B

Explanation

Rationale

A. Monitoring blood glucose levels is important, especially in critically ill patients, as hyperglycemia can worsen outcomes in septic shock. However, it is not the most critical intervention in the immediate management of septic shock.

B. Monitoring intake and output (I/O) is essential for assessing fluid balance, which is crucial in managing septic shock. Maintaining a strict I/O helps in determining fluid resuscitation needs and evaluating response to treatment. This intervention is important but may not be the most critical initially.

C. Assessing warmth of extremities is important as it helps in evaluating peripheral perfusion, which can be compromised in septic shock. Cold extremities can indicate poor tissue perfusion and may prompt the need for interventions such as fluid resuscitation.

D. Keeping the head of the bed elevated to 45 degrees is a specific intervention aimed at improving oxygenation and respiratory function, particularly in patients who may be mechanically ventilated or at risk of respiratory compromise. While this is an important intervention, it is not directly related to managing septic shock itself.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.

Correct Answer is ["B","E","F"]

Explanation

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is B

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?

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take? Reference Range: High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?