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 B
Explanation
Choice A rationale:
Emphasize that using safe sex practices removes the risk of STIs. Rationale: While promoting safe sex practices is essential in preventing STIs, this response is not directly addressing the client's situation. The client already reports having unprotected sex, so this choice does not provide relevant information or address the potential consequences.
Choice B rationale:
Explain that reinfections occur from sex with untreated partners. Rationale: This is the correct response. Syphilis is a sexually transmitted infection that can be treated with antibiotics, but reinfections can occur if sexual partners are not treated. This response provides essential information about the potential consequences of unprotected sex with untreated partners.
Choice C rationale:
Clarify that all STIs are transmitted through sexual intercourse. Rationale: While this statement is accurate in a general sense, it does not specifically address the client's situation or the risks associated with syphilis. It lacks the focus needed to educate the client effectively about their current situation.
Choice D rationale:
Provide counseling that most contraceptives protect against infection. Rationale: This response is inaccurate. Contraceptives primarily aim to prevent pregnancy, not protect against STIs. Therefore, it does not address the client's concern or provide relevant information about syphilis.
Correct Answer is C
Explanation
Choice A rationale:
Domestic violence assistance is an important topic, but it falls under secondary and tertiary prevention rather than primary disease prevention, which is the focus of this community outreach program. Primary prevention aims to prevent the disease from occurring in the first place, while domestic violence assistance addresses an existing issue.
Choice B rationale:
Blood pressure screening is valuable for early detection of hypertension, but it also falls under secondary prevention. Primary prevention focuses on preventing the onset of diseases through measures such as immunizations, health education, and lifestyle modifications.
Choice D rationale:
Outreach for support group information is essential for clients with chronic conditions or specific needs. However, it is not primarily related to preventing diseases at the population level, which is the primary goal of this community outreach program. This topic may be more relevant to secondary and tertiary prevention efforts.
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