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 B
Explanation
Choice A rationale
Phobia is characterized by an excessive and irrational fear response. In this case, the patient’s symptoms do not indicate a specific fear, but rather general distress and intrusive thoughts related to a traumatic event.
Choice B rationale
The patient’s symptoms, which include distressing thoughts and memories of the house collapsing, difficulty sleeping, and a significant change in mood, are indicative of acute stress disorder related to traumatic stress exposure. Acute stress disorder can occur within a month of experiencing a traumatic event, like a natural disaster.
Choice C rationale
Hallucinations involve perceiving something that is not present. The patient’s symptoms do not include any indications of hallucinations.
Choice D rationale
Separation anxiety involves excessive fear or anxiety about separation from those to whom the individual is attached. The patient’s symptoms do not indicate a fear of separation, but rather distress related to a traumatic event.
Correct Answer is C
Explanation
Choice A rationale
Using the inhaler only when the patient is really short of breath is not an incorrect use of the inhaler. However, it might indicate that the patient is not managing their COPD effectively, as rescue inhalers like albuterol are meant to be used for quick relief of acute symptoms.
Choice B rationale
Having a hard time inhaling and holding the breath after squeezing the inhaler might suggest that the patient is not using the inhaler correctly. However, the patient’s statement that they “do their best” suggests that they are aware of the correct technique and are trying to follow it.
Choice C rationale
Swallowing after squeezing the inhaler is a clear indication of incorrect use. The medication from the inhaler is meant to be inhaled into the lungs, not swallowed. Swallowing the medication would lead to less of it reaching the lungs, reducing its effectiveness. The wave of nausea the patient experiences could be a side effect of swallowing the medication.
Choice D rationale
Shaking the inhaler several times before starting is actually part of the correct technique for using many types of inhalers.
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