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.

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Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

Correct choices;

Gravida 5, para 5 (G5P5)

This means the client has been pregnant 5 times and has given birth 5 times. Multiparity (having had multiple pregnancies and deliveries) is a risk factor for PPH due to uterine overdistension, which can lead to poor uterine tone and difficulty in contracting effectively after delivery.

Delivery of a 9 lb 1 oz (4.1 kg) baby

Larger babies are associated with an increased risk of PPH. The weight of the baby suggests a potentially larger placental surface area and increased uterine distension during pregnancy, which can contribute to uterine atony post-delivery.

Labor for 25 hours

Prolonged labor can lead to uterine exhaustion, where the uterus may not contract effectively after delivery, predisposing the client to PPH.

Forceps-assisted delivery

Instrumental deliveries, including forceps, can cause trauma to the birth canal, including the cervix, vagina, and perineum, increasing the risk of lacerations and bleeding.

Epidural anesthesia

Epidurals can mask the pain associated with uterine atony, which may delay the diagnosis of PPH. It's important to closely monitor uterine tone and blood loss in clients who have had epidurals.

4th degree laceration

Explanation: A 4th degree laceration involves the perineum and extends through the anal sphincter complex. Such extensive trauma increases the risk of significant bleeding postpartum.

Estimated blood loss of 600 mL

Although this is within the normal range of blood loss immediately after delivery, it still signifies that the client has experienced significant hemorrhage, putting her at higher risk for ongoing bleeding.

A. Avoid the consumption of wine, beer, and coffee. B. Substitute natural fruit juices for carbonated drinks. C. Encourage active range of motion to limit stiffness. D. Use electric heating pad when pain is at its worse.

Correct Answer is A

Explanation

Rationale

A. This instruction is relevant because alcohol, particularly beer and wine, can exacerbate gout symptoms due to their purine content, which can lead to increased uric acid levels in the blood. High uric acid levels can contribute to gouty arthritis flare-ups.

B. This instruction promotes a healthier dietary choice, as carbonated drinks often contain added sugars and contribute to excess calorie intake, which can contribute to obesity. However, fruit juices can also be high in sugars and should be consumed in moderation. Encouraging water as the primary beverage choice would be even better for weight loss and overall health.

C. This instruction is generally beneficial for maintaining joint mobility and preventing stiffness, which can be particularly important for someone experiencing pain in a weight-bearing joint like the ankle. However, if the pain is severe and acute, active range of motion exercises may need to be introduced gradually and under guidance to avoid exacerbating the condition.

D. Heat therapy can provide symptomatic relief for joint pain associated with conditions like gouty arthritis. However, it is important to ensure that heat is not applied during acute inflammation or gout flare-ups, as it can potentially worsen symptoms. Cold therapy may be more appropriate during active inflammation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

Correct choices;

Gravida 5, para 5 (G5P5)

Delivery of a 9 lb 1 oz (4.1 kg) baby

Labor for 25 hours

Forceps-assisted delivery

Epidural anesthesia

4th degree laceration

Estimated blood loss of 600 mL

Correct Answer is A

Explanation

Exhibits The nurse discusses the keep to balance energy intake and output to maintain weight Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?

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.

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity. Which test should the nurse schedule the client for evaluation of the symptoms?

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPS. Which intervention should the home health nurse implement to ensure adequate care for all clients?

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?