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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
The findings suggest that the client’s condition has improved.
Choice A rationale
A total blood loss of 800 mL is a significant amount, but it is within the normal range for blood loss during and after childbirth. Therefore, this does not necessarily put the client at risk for hypovolemia.
Choice B rationale
A fundus that is firm and at the level of the umbilicus indicates that the uterus is contracting properly after childbirth, which helps to prevent excessive bleeding.
Choice C rationale
The expulsion of multiple large clots could indicate that the body is effectively clotting blood, which can prevent excessive bleeding.
Choice D rationale
A blood pressure of 110/80 mm Hg, a heart rate of 66 beats/minute, and an oxygen saturation of 98% on room air are all within normal ranges, indicating that the client is stable and not at risk for hypovolemia.
Correct Answer is D
Explanation
Choice A rationale
Assigning the newly hired UAP to clients who require the least complex level of care might not be the best approach. While it might seem logical to assign less complex cases to a new hire, this could limit the UAP’s opportunities for learning and growth.
Choice B rationale
Reviewing the UAP’s skills checklist and experience with the person who hired the UAP is an important step, but it might not be enough to ensure adequate care for all clients. The skills and experiences listed on a checklist might not fully reflect the UAP’s actual abilities in a real-world setting.
Choice C rationale
Asking the most experienced UAP on the team to partner with the newly hired UAP could be beneficial for mentorship and guidance. However, this might not be the most efficient use of resources, especially if the experienced UAP has to spend a significant amount of time supervising the new hire.
Choice D rationale
Assessing the newly hired UAP’s competency level by observing the UAP deliver care is the most effective way to ensure adequate care for all clients. This allows the nurse to directly evaluate the UAP’s skills and abilities in a real-world setting, and to provide immediate feedback and guidance as needed.
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