A male client who is admitted with bipolar disorder, and manic psychosis, is placed in seclusion after unsuccessful attempts to de-escalate him 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 intramuscularly STAT prior to seclusion.
Which intervention is most important for the nurse to implement immediately after seclusion?
Release the client as soon as composure is regained.
Observe for extrapyramidal symptoms, such as dystonia.
Secure the room with padded walls and minimal furnishings.
Provide one-on-one observation at all times.
The Correct Answer is B
Choice B 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 to cause extrapyramidal side effects. Identifying and managing these side effects promptly is crucial to ensure the client's safety.
Choice A rationale:
Releasing the client as soon as composure is regained may not be safe if the client is still at risk of harming themselves or others. Monitoring for the resolution of symptoms and stabilization is important before releasing the client.
Choice C rationale:
Securing the room with padded walls and minimal furnishings is not the immediate priority. While seclusion rooms should be safe and comfortable, observing for potential side effects takes precedence.
Choice D rationale:
Providing one-on-one observation at all times is a resource-intensive intervention and may not be necessary for all clients. Observing for extrapyramidal symptoms is more targeted and appropriate in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. Suicidal ideation is not a diagnosis in itself but rather a symptom or thought process associated with various mental health conditions.
Choice B rationale:
This statement is incorrect. Suicidal ideation can occur in individuals of all age groups, not just in older adults. It is not limited to any specific age demographic.
Choice C rationale:
This statement is incorrect. Suicidal ideation does not always involve a detailed plan for self-harm. It can range from fleeting thoughts of self-harm to more detailed plans, but the severity can vary widely.
Choice D rationale:
This statement is accurate. Suicidal ideation can be a symptom of various underlying mental health conditions, including depression, anxiety disorders, bipolar disorder, and others. It involves thoughts of self-harm or suicide, which may or may not be accompanied by specific plans.
Correct Answer is A
Explanation
Choice A rationale:
Instructing the client to bring all medications, supplements, and herbs currently being taken to the next clinic appointment (Choice A) is the best course of action. This allows the healthcare provider to review the client's entire medication regimen, identify any potential interactions or duplications, and make appropriate adjustments. It promotes medication safety and ensures that the client receives the most effective and safe treatment.
Choice B rationale:
Using a medication reminder system (Choice B) is a helpful suggestion but does not address the issue of potential duplications or interactions between medications. While a reminder system can improve adherence, it does not provide a comprehensive solution to the problem of multiple prescriptions for the same indication.
Choice C rationale:
Making certain a family member knows the name and use of all medications currently being taken (Choice C) is a useful practice for medication safety but may not be sufficient to address the issue of multiple prescriptions. Relying solely on a family member's knowledge may lead to misunderstandings or omissions in the medication regimen.
Choice D rationale:
Do not take any over-the-counter drugs while taking medications prescribed by a healthcare provider (Choice D) is a relevant piece of advice for medication safety. However, it does not directly address the issue of multiple prescriptions for the same indication. It is essential for the client to have a complete and accurate record of all medications, both prescribed and over-the-counter, to ensure safe and effective treatment.
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