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.

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 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.

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Free Nursing Study Resources

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

Explanation

Choice A rationale:

Monitoring ETT markings between 22 and 26 cm at the teeth line is essential to ensure proper placement of the endotracheal tube (ETT). This helps confirm that the ETT is positioned correctly in the trachea.

Choice B rationale:

Checking for capillary refill is not a reliable method for verifying the placement of an ETT. It is more indicative of peripheral circulation and not related to airway management.

Choice C rationale:

Obtaining a portable chest x-ray is a crucial step to verify the exact placement of the ETT within the trachea and to rule out potential complications such as pneumothorax.

Choice D rationale:

Assessing for symmetrical chest movement is important because unequal chest rise and fall could indicate an issue with ETT placement or lung function.

Choice E rationale:

Auscultating for bilateral breath sounds is another method to confirm that the ETT is correctly positioned in the trachea and that both lungs are being ventilated adequately.

A. Sinus tachycardia. B. Menstrual cramps. C. Hypertension. D. Amenorrhea. E. Amenorrhea.

Correct Answer is D

Explanation

Choice A rationale:

Sinus tachycardia may occur in response to various stressors or physiological conditions but is not directly related to anorexia nervosa or severe malnutrition. It is not the primary pathological process resulting from this condition.

Choice B rationale:

Menstrual cramps are not a pathological process but rather a symptom that may result from hormonal changes or other factors. While amenorrhea (absence of menstrual periods) is a common feature of anorexia nervosa, menstrual cramps are not a primary concern in this context.

Choice C rationale:

Hypertension is not typically associated with anorexia nervosa or severe malnutrition. In fact, individuals with anorexia nervosa often experience hypotension (low blood pressure) due to dehydration and nutritional deficiencies.

Choice D rationale:

Amenorrhea is the primary pathological process resulting from the adolescent's consistent maladaptive behavior of anorexia nervosa. Severe malnutrition and low body weight can disrupt the normal menstrual cycle and lead to amenorrhea. This is a significant concern for individuals with anorexia nervosa and can have long-term health implications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? (Select all that apply.).

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

Explanation

The nurse is assessing an adolescent female diagnosed with anorexia nervosa who is admitted to the unit with severe malnutrition and electrolyte imbalance. Which pathological process results from the adolescent's consistent maladaptive behavior?

Correct Answer is D

Explanation

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?

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

A client with a long history of migraine headaches asks the nurse if there are non-pharmaceutical ways to help obtain pain relief. Which intervention should the nurse offer?

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

A nurse is caring for a client who has meningitis caused by Streptococcus pneumoniae. The provider orders penicillin G IV for this client. Before administering the medication, which of the following actions should the nurse take?

The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

A nurse is caring for a client who has variant angina and is prescribed verapamil. Which of the following are expected outcomes of this medication? (Select all that apply.)

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?