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 B
Explanation
Choice A rationale:
Notifying the healthcare provider that the client is having difficulty using the spirometer may be necessary if the client is unable to use the device correctly despite encouragement and education. However, the initial action should be to encourage the client and provide support.
Choice B rationale:
Encouraging the client to continue inhaling slowly into the spirometer until the goal is met is the correct action. Incentive spirometry is used to improve lung function, and it is essential for the client to use it correctly and meet their goals to achieve the desired outcomes.
Choice C rationale:
Offering to demonstrate the correct use of the incentive spirometer to the client may be helpful if the client is struggling to use it properly. However, the initial response should be to encourage the client and provide guidance.
Choice D rationale:
Reminding the client to cough after each use of the spirometer to help clear the lungs is not the most appropriate action in this situation. While coughing may be beneficial, the primary focus should be on achieving the goals of the incentive spirometry.
Correct Answer is D
Explanation
Choice A rationale:
Washing the patient's left side first and then moving to the right side does not demonstrate an individualized approach or consideration for the patient's preferences and abilities. It is important to involve the patient in the decision-making process, especially when they have hemiparesis, to promote their autonomy and comfort.
Choice B rationale:
Washing the patient's right side first and then moving to the left side does not consider the patient's preference and may not align with their abilities or comfort. It is essential to prioritize the patient's preferences and needs.
Choice C rationale:
Washing both sides of the patient at the same time, starting from the head and moving down, may not be feasible or comfortable for the patient, especially if they have hemiparesis. This approach does not demonstrate an individualized care plan based on the patient's specific condition.
Choice D rationale:
Asking the patient which side they prefer to wash first and then following their preference is the most patient-centered and appropriate approach. This approach respects the patient's autonomy and ensures that their needs and comfort are prioritized during the bathing process. It allows for individualized care based on the patient's abilities and preferences.
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