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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

High-density lipoprotein (HDL) cholesterol is known as the “good” cholesterol because it helps remove other forms of cholesterol from your bloodstream. Higher levels of HDL cholesterol are associated with a lower risk of heart disease. Therefore, an HDL level of 85 mg/dL (2.2 mmol/L) is helpful in reducing cardiac risk.

Choice B rationale

Encouraging the client to reduce consumption of fatty foods is not necessary in this case as the client’s HDL level is already high, which is beneficial for heart health.

Choice C rationale

Asking the client about hereditary cardiac risk factors is not the most relevant action in this case. The client’s HDL level is already high, which is beneficial for heart health.

Choice D rationale

Explaining that the client may need medication therapy is not necessary in this case as the client’s HDL level is already high, which is beneficial for heart health.

A. Uterine atony B. Wound dehiscence C. Infection D. Hemorrhage

Correct Answer is A

Explanation

Choice A rationale

Uterine atony refers to a condition where the uterus fails to contract sufficiently during and after childbirth. This lack of contraction can lead to excessive bleeding, also known as postpartum hemorrhage. This is because the contractions of the uterus after delivery help to compress the blood vessels and prevent bleeding. Therefore, uterine atony can cause a patient to hemorrhage.

Choice B rationale

Wound dehiscence refers to a surgical complication where an incision reopens either internally or externally. It can cause pain, infection, and organ protrusion. However, it is not directly associated with hemorrhaging.

Choice C rationale

Infection refers to the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. While severe infections can lead to sepsis and disseminated intravascular coagulation, which can cause bleeding, they do not directly cause hemorrhaging.

Choice D rationale

Hemorrhage is a symptom, not a condition. It refers to excessive bleeding which can occur due to various conditions, including uterine atony.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client informs the nurse of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). What action should the nurse take?

Correct Answer is A

Explanation

The nurse has reviewed the patient’s chart.The nurse recognizes that this patient is hemorrhaging due to which condition?

Correct Answer is A

Explanation

While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.What is the most appropriate action for the nurse to take?

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)?

An elderly patient who had a fall at a store is admitted with a potential right hip fracture.What assessment finding should the nurse report to the healthcare provider?

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis.The client reports having unprotected sex.Which response should the nurse provide?

The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit.Which prescription should the nurse implement first?

After administering the prescribed albuterol nebulizer treatment, what should the nurse assess?

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.