A male client who is admitted with bipolar disorder, 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 for causing 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 C
Explanation
Choice A rationale:
Addiction involves a dependence on a substance or behavior that leads to withdrawal symptoms when the substance or behavior is discontinued. The client's handwashing behavior is not related to addiction.
Choice B rationale:
Phobia refers to an irrational and intense fear of a specific object or situation. While the client's avoidance of sitting on chairs in the day area may be related to anxiety, it does not represent a specific phobia.
Choice C rationale:
Compulsion is the correct answer because the client's handwashing ritual is an example of compulsive behavior. Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession or according to rigid rules. In this case, the client is compelled to engage in the ritual to alleviate anxiety or distress.
Choice D rationale:
Obsession refers to persistent and intrusive thoughts, urges, or images that cause distress and anxiety. While the client's handwashing ritual may be related to obsessive thoughts about cleanliness, the primary clinical behavior being exhibited is the compulsive handwashing itself.
Correct Answer is D
Explanation
Choice D rationale:
"Antiembolism stockings on, leg exercises performed hourly" indicates that activities to prevent postoperative venous stasis were performed correctly. This combination ensures both mechanical prophylaxis (antiembolism stockings) and physical activity (leg exercises) to prevent blood clots in postoperative patients.
Choice A rationale:
"Leg exercises not performed because of placement of antiembolism hose" is not the correct approach. Leg exercises should be encouraged even when antiembolism stockings are worn, as they have complementary benefits in preventing venous stasis.
Choice B rationale:
"Antiembolism stockings removed hourly during leg exercises" is not recommended. Antiembolism stockings should be worn continuously to be effective in preventing venous stasis.
Choice C rationale:
"Client demonstrates the ability to move all extremities well" is a good sign of the client's mobility but does not confirm that the specific activities to prevent postoperative venous stasis were performed correctly. The combination of stockings and leg exercises is more comprehensive.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.