A client with bipolar disorder, manic psychosis, 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.
What is the most important intervention for the nurse to implement immediately after seclusion?
Secure the room with padded walls and minimal furnishings.
Release the client as soon as composure is regained.
Provide one-on-one observation at all times.
Observe for extrapyramidal symptoms, such as dystonia.
The Correct Answer is D
Choice A rationale
While securing the room with padded walls and minimal furnishings is an important aspect of seclusion, it is not the most important intervention immediately after seclusion. The safety of the client is paramount, and observing for extrapyramidal symptoms, such as dystonia, is crucial as haloperidol, an antipsychotic medication known to have the potential for causing extrapyramidal side effects, was administered.
Choice B rationale
Releasing the client as soon as composure is regained is not the most important intervention. The client’s mental and physical health needs to be continuously monitored, especially for side effects of the medication administered.
Choice C rationale
Providing one-on-one observation at all times is important, but it is not the most important intervention immediately after seclusion. The priority is to monitor for any adverse effects of the medication administered.
Choice D rationale
Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential for causing extrapyramidal side effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Based on the information provided, the client is most likely experiencinganorexia nervosa.This is suggested by her significant weight loss, bradycardia, hypothermia, lanugo-type hair, and her expressed fear of gaining weight despite being underweight. However, this is a preliminary assessment and a definitive diagnosis should be made by a healthcare professional.
Actions the nurse should take to address this condition include:
- Acknowledge anxious feelings: It’s important to validate the client’s feelings and fears about food and weight gain.This can help build trust and facilitate further discussion about her health.
- Provide emotional support: Emotional support is crucial in managing eating disorders.The nurse can provide reassurance, listen empathetically, and encourage the client to express her feelings.
Parameters the nurse should monitor to assess the client’s progress include:
- Nutritional intake: Monitoring the client’s food and fluid intake can help assess her nutritional status and response to treatment.
- Weight and BMI: Regular monitoring of the client’s weight and BMI can provide objective measures of her nutritional status and response to treatment.
Correct Answer is C
Explanation
Choice A rationale
While altered taste sensation can occur with radiation treatment, it’s not the most likely reason for an imbalance in nutritional intake in this scenario.
Choice B rationale
Fatigue can be a side effect of radiation treatment, but it’s not the primary reason for an imbalance in nutritional intake in this case.
Choice C rationale
Pain during eating is the most likely cause of imbalanced nutritional intake in this scenario. The patient’s laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the patient from eating, leading to decreased nutritional intake.
Choice D rationale
Nausea can occur with radiation treatment, but it’s not the primary reason for an imbalance in nutritional intake in this case.
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