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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Correct Answer is B

Explanation

Choice A rationale:

Objective data. Rationale: Objective data are observable and measurable facts obtained through physical examination or diagnostic tests. The statement incorrectly labels the data as objective when it is, in fact, based on the client's feelings and perceptions, making it subjective.

Choice B rationale:

Subjective data. Rationale: Subjective data are information provided by the client, including their feelings, perceptions, and experiences. The statement correctly labels the data as subjective, as it reflects the client's report of thirst and hunger.

Choice C rationale:

Primary data. Rationale: Primary data are original data collected directly from the source, such as a client's medical history or interview. However, this classification does not address the nature of the data as being subjective or objective, so the statement does not provide a complete answer.

Choice D rationale:

Secondary data. Rationale: Secondary data are data obtained from sources other than the client, such as medical records or research studies. Similar to choice C, this classification does not address the nature of the data as being subjective or objective.

A. Substitute natural fruit juices for carbonated drinks. B. Encourage active range of motion to limit stiffness. C. Use electric heating pad when pain is at its worst. D. Avoid the consumption of wine, beer, and coffee.

Correct Answer is B

Explanation

Choice A rationale:

Substituting natural fruit juices for carbonated drinks may be a beneficial dietary change, but it does not address the client's immediate issue of severe pain and inability to bear weight on the right ankle. This choice does not directly address the client's current problem and should not be the priority instruction in discharge teaching.

Choice B rationale:

Encouraging active range of motion to limit stiffness is the most appropriate instruction in this situation. The client's inability to bear weight on the right ankle after making dietary changes may be related to musculoskeletal issues or gouty arthritis. Active range of motion exercises can help prevent stiffness and improve joint function.

Choice C rationale:

Using an electric heating pad when pain is at its worst may provide some comfort, but it does not address the underlying cause of the severe pain in the right ankle. It is important to address the cause of the pain rather than relying solely on symptom management.

Choice D rationale:

Avoiding the consumption of wine, beer, and coffee may be relevant for some medical conditions, but it does not directly address the client's current problem of severe ankle pain and inability to bear weight. It is not the most immediate concern.

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Naxlex Comprehensive Predictor Exams

A nurse is documenting the data collected from an ongoing assessment of a client who has diabetes mellitus. The nurse writes, “The client reports feeling thirsty and hungry all the time.” How should the nurse label this type of data?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

A nurse is reviewing laboratory results for a client who has been taking amoxicillin-clavulanate (Augmentin) for a bacterial respiratory tract infection. Which of the following findings should alert the nurse to a possible adverse effect of this medication? (Select all that apply.).

A nurse is teaching a group of older adults about the effects of aging on the neurological system. Which of the following statements should the nurse include as correct? (Select all that apply.).

Patient Data Exhibits What is the rationale for the order of supplemental oxygen 10 L/min via nasal cannula? Select the best answer.

After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields. Which action should the nurse take next based on the assessment?

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?