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.

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Correct Answer is B

Explanation

Choice A rationale

While fresh fruits and vegetables are part of a healthy diet, they are not specifically recommended for the prevention of osteoporosis. They do not contain significant amounts of calcium, which is crucial for bone health.

Choice B rationale

Low fat dairy products are a good source of calcium, which is essential for bone health and the prevention of osteoporosis.

Choice C rationale

While water and herbal teas can contribute to overall hydration, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.

Choice D rationale

While iron-rich meats contribute to overall health, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.

A. Decreased range of motion B. Pain with movement C. Reduced strength in left upper extremity D. Reduced pulse distal to injury E. Coolness of the skin

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

Choice A rationale

Decreased range of motion is generally associated with a rotator cuff injury. This is because the rotator cuff is a group of muscles and tendons that surround the shoulder joint, keeping the head of the upper arm bone firmly within the shallow socket of the shoulder. When these muscles or tendons are injured, it can limit the shoulder’s range of motion.

Choice B rationale

Pain with movement can be a symptom of both a rotator cuff injury and a humeral fracture. Both conditions involve structures that are integral to the movement of the arm, and damage to these structures can cause pain when they are moved or put under strain.

Choice C rationale

Reduced strength in the left upper extremity is more commonly associated with a rotator cuff injury. The rotator cuff is responsible for the stability of the shoulder joint and enables the arm to lift and rotate. An injury to the rotator cuff can therefore lead to a reduction in the strength of the arm.

Choice D rationale

Reduced pulse distal to the injury is more commonly associated with a humeral fracture. This is because a fracture to the humerus could potentially damage the blood vessels running along the bone, leading to a reduced pulse further down the arm.

Choice E rationale

Coolness of the skin is more commonly associated with a humeral fracture. This could be due to damage to the blood vessels, leading to reduced blood flow and therefore a lower skin temperature.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching an older client about the prevention of osteoporosis.Which foods should the nurse recommend to the client to increase in the diet?

Correct Answer is B

Explanation

The same 68-year-old male patient from the previous as been assessed. For each of the following findings, indicate whether they are generally associated with a rotator cuff injury or a humeral fracture.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

After receiving a change of shift report for patients on a medical-surgical unit, which task should the nurse delegate to an unlicensed assistive personnel (UAP)?

After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient.During a follow-up visit at the community clinic, the nurse observes that the patient has developed jaundice.Which action should the nurse take?

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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?

When developing an educational program for older adult clients who are being discharged with new antihypertensive medications, which characteristics should the nurse ensure that the educational materials include? Select all that apply.

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