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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Free Nursing Study Resources

Correct Answer is A

No explanation

A. Contains a list with definitions of unfamiliar terms. B. Written at a twelfth-grade reading level. C. Uses common words with few syllables. D. Uses pictures to help illustrate complex ideas. E. Printed using a 12-point type font.

Correct Answer is ["A","D"]

Explanation

Choice A rationale:

The educational materials should contain a list with definitions of unfamiliar terms because older clients may not be familiar with medical terminology. Providing definitions can enhance their understanding of the new antihypertensive medications and promote medication adherence.

Choice B rationale:

Writing materials at a twelfth-grade reading level may not be appropriate for older clients. Many older individuals may have lower literacy levels, and using complex language can lead to confusion and hinder comprehension. Simple and clear language is more effective in educating this population.

Choice C rationale:

Using common words with few syllables is important for ensuring that older clients can easily understand the educational materials. Complex language and lengthy words can make it difficult for them to grasp important information about their antihypertensive medications.

Choice D rationale:

Using pictures to help illustrate complex ideas is essential when educating older clients. Visual aids can enhance comprehension and retention of information, especially for individuals who may have cognitive impairments or difficulty with written text.

Choice E rationale:

Printing materials using a 12-point type font is important for ensuring that the text is easy to read for older clients. Smaller fonts can be challenging for individuals with visual impairments, and readability is crucial for effective education.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

Correct Answer is A

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications.The nurse should ensure that the educational materials include which characteristics? (Select all that apply.).

Correct Answer is ["A","D"]

Explanation

The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?

A nurse is teaching a client with hypertension about antihypertensive drugs.Which of the following statements by the client indicates an understanding of the teaching?

A client has been diagnosed with depression and has a history of suicide attempts.What intervention is essential for the nurse to implement?

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

A nurse is administering tetracycline to a client who has acne vulgaris.The client tells the nurse that he usually takes calcium supplements with his meals.How should the nurse respond?

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing.Which action should the nurse take first?

Patient Data. Exhibits The nurse has called the physician and is anticipating orders. Select the actions that would help with the listed treatment goals. Select all that apply.