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. Major Depressive Disorder (MDD) is typically more severe than dysthymia and is characterized by recurrent episodes of severe depression lasting at least two weeks.
Choice B rationale:
This statement is incorrect. Dysthymia is not characterized by alternating episodes of mania and depression. It is a chronic, low-grade depressive disorder.
Choice C rationale:
This statement is incorrect. Dysthymia can impair social and occupational functioning, similar to MDD. Both conditions can have a significant impact on a person's daily life.
Choice D rationale:
This statement is accurate. Dysthymia is a chronic depressive disorder that lasts for at least two years but is generally less severe than MDD. It is characterized by persistent, milder symptoms of depression.
Correct Answer is B
Explanation
Choice A rationale:
Granulating tissue in a foot ulcer is a positive sign of wound healing, but it may not be directly related to the effectiveness of pregabalin in treating diabetic peripheral neuropathy. The primary goal of pregabalin in this context is to reduce pain and neuropathic symptoms.
Choice B rationale:
A reduced level of pain is the most relevant indicator of the effectiveness of pregabalin in treating diabetic peripheral neuropathy. Pregabalin is an antiepileptic medication used to manage neuropathic pain. A decrease in pain indicates that the medication is effectively managing the client's symptoms.
Choice C rationale:
Improved visual acuity is not directly related to the effectiveness of pregabalin in treating diabetic peripheral neuropathy. Pregabalin primarily targets neuropathic pain and sensory symptoms, not visual function.
Choice D rationale:
A full volume of pedal pulses is a positive sign of adequate circulation in the lower extremities, but it may not be directly related to the effectiveness of pregabalin in treating neuropathy symptoms. The primary goal of pregabalin in this context is pain management.
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