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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Avocados and cheese are not specifically recommended for a client with a postoperative wound infection. While a balanced diet is important for overall health, yogurt or buttermilk is a better choice due to their probiotic content, which may promote gut health and support the immune system.

Choice B rationale:

Fresh fruits are generally a healthy dietary choice, but they are not particularly relevant to the management of a postoperative wound infection. The emphasis for this client should be on foods that support wound healing and immune function, such as yogurt or buttermilk.

Choice D rationale:

Green leafy vegetables are rich in vitamins and minerals, but they are not a primary focus for a client with a postoperative wound infection. Again, the emphasis should be on foods that support the immune system and overall recovery, such as yogurt or buttermilk.

A. Keep head of bed raised 45 degrees. B. Maintain strict intake and output. C. Monitor blood glucose level. D. Assess warmth of extremities.

Correct Answer is A

Explanation

Choice A rationale:

Keeping the head of the bed raised 45 degrees is a crucial intervention in septic shock. This position helps improve oxygenation and reduces the risk of aspiration. It promotes better lung function and can help maintain a higher mean arterial pressure, which is important in the management of sepsis.

Choice B rationale:

Maintaining strict intake and output is important for assessing fluid balance, but it is not the most critical intervention when a client is in septic shock. Hemodynamic stability and oxygenation take precedence in this situation.

Choice C rationale:

Monitoring blood glucose levels is an essential aspect of care, especially in critically ill patients. However, it is not the most important intervention in the immediate management of septic shock.

Choice D rationale:

Assessing the warmth of extremities is important for circulatory assessment, but it is not the most crucial intervention in septic shock. Hemodynamic support and maintaining oxygenation are higher priorities.

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes the antibiotic cefdinir 300 mg by mouth every 12 hours for a client with a postoperative wound infection.Which foods should the nurse encourage this client to eat?

Correct Answer is C

Explanation

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago.The healthcare provider prescribes a sepsis protocol to be initiated.Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is A

Explanation

An adult male was diagnosed with stage IV lung cancer three weeks ago.His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies.Which is the best response by the nurse?

A nurse is providing interventions for a client with panic disorder.Which interventions should the nurse include in the plan of care? (Select all that apply).

The nurse completes percussion of the abdomen on an older adult client.Which finding is considered normal for this client?

The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting exenatide.Which information should be included in the discharge instructions?

A nurse is teaching a group of older adults about the effects of aging on the neurological system.Which of the following statements should the nurse include as correct? (Select all that apply.).

A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement?