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.

Answer and Explanation

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

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Free Nursing Study Resources

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

Explanation

Based on the client’s history and physical, the following areas increase the risk for postpartum hemorrhage:

Gravida 5 Para 5 (G5P5): Multiparity (having given birth 5 times) can increase the risk of postpartum hemorrhage due to uterine atony (lack of muscle tone) resulting from repeated stretching of the uterus.
Delivery of a 9 lb 1 oz (4.1 kg) baby: Macrosomia (large baby) can overstretch the uterus, increasing the risk of uterine atony and postpartum hemorrhage.
Labor for 25 hours and use of forceps for delivery: Prolonged labor and instrumental delivery can lead to uterine fatigue and atony, increasing the risk of postpartum hemorrhage.
4th degree laceration: Severe lacerations can lead to significant blood loss.
Estimated blood loss was 600 mL after delivery: This is a significant amount of blood loss and could indicate a risk for further hemorrhage.
Lochia rubra moderate with small clots: This could indicate ongoing blood loss.

A. Notify your healthcare provider if you start having abdominal pain. B. Inject exenatide within 30 minutes before or after a meal. C. Exenatide acts in the same way as insulin in lowering blood glucose. D. There are no precautions about taking exenatide with other medications.

Correct Answer is A

Explanation

Choice A rationale

Exenatide is a medication used to improve blood sugar control in adults with type 2 diabetes. One of the potential side effects of exenatide is pancreatitis, which can cause severe abdominal pain. Therefore, patients should be instructed to notify their healthcare provider if they start having abdominal pain after starting exenatide.

Choice B rationale

Exenatide should be injected within 60 minutes (1 hour) before the morning and evening meal (or before the two main meals of the day, at least 6 hours apart), not 30 minutes before or after a meal. Therefore, this instruction is incorrect.

Choice C rationale

Exenatide does not act in the same way as insulin. While both insulin and exenatide help to control high blood sugar, they work in different ways. Insulin allows sugar in your blood to enter your cells, while exenatide works by increasing the release of insulin when blood sugar levels are high, decreasing the amount of glucose produced and released by the liver, and slowing gastric emptying.

Choice D rationale

There are precautions about taking exenatide with other medications. For example, exenatide may affect the absorption of some orally administered drugs due to its effect on gastric emptying. Therefore, patients should be advised to take oral medications that require rapid absorption at least 1 hour before injecting exenatide.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

The nurse is preparing discharge instructions for a patient with type 2 diabetes mellitus who will be starting exenatide.What information should be included in the discharge instructions?

Correct Answer is A

Explanation

A patient informs the nurse about starting an exercise program a month ago to lose weight and improve sleep.The patient states, “It still takes at least two hours to fall asleep at night.”. What action should the nurse take?

A patient has been prescribed 1 L of Lactated Ringer’s IV to be infused over a 12-hour period. The IV administration set delivers 15 gtt/mL. What should be the infusion rate in gtt/min? (Provide a numerical value only. If rounding is required, round to the nearest whole number.)

As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.Which interventions should you perform?

A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

A patient weighing 132 lb is prescribed lorazepam 44 mcg/kg IV to be administered 20 minutes before a scheduled procedure. The medication is available in a 2 mg/mL vial. How many mL should the nurse administer? Round off to 2 d.p. (This is a medical math nd does not require options.)

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?