For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of Haloperidol is whether

less-restrictive alternatives have been tried without success

the medication will make the work of the staff easier or safer

the client is willing to accept the medication

the clients behavior indicates possible danger to self, others or the environment

Answer and Explanation

The Correct Answer is D

A. Less-restrictive alternatives have been tried without success: While it is important to explore less-restrictive alternatives before resorting to medication, the immediate concern is the client's safety and the safety of others. If the client's behavior poses a significant risk, prompt intervention may be necessary.

B. The medication will make the work of the staff easier or safer: While staff safety is important, the primary consideration for administering a prn dose of Haloperidol is the clinical need based on the client's behavior and potential danger to themselves, others, or the environment.

C. The client is willing to accept the medication: Client willingness to accept medication is relevant for promoting collaboration in treatment, but the urgency in administering a prn dose is often based on the client's behavior and the level of risk they pose.

D. The client's behavior indicates possible danger to self, others, or the environment: This is the most critical factor in determining the need for a prn dose. If a client's behavior poses a significant risk, such as aggression, violence, or extreme agitation, administering a prn dose of medication may be necessary to ensure safety and prevent harm.

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Correct Answer is B

Explanation

A. Altered thought process related to hallucinations: While altered thought processes are common in manic episodes, hallucinations are not typically associated with mania in Bipolar I disorder. Hallucinations are more commonly seen in psychotic disorders.

B. Risk for violence related to poor impulse control and judgment: This is the correct priority diagnosis. During a manic episode, individuals may have impaired impulse control and poor judgment, increasing the risk of impulsive and potentially violent behaviors. Ensuring the safety of the client and others is the priority.

C. Altered thought process related to poor judgment: While altered thought processes and poor judgment are characteristic of mania, the specific concern in this scenario is the potential for violence. The risk for violence takes precedence as a priority nursing diagnosis.

D. Social isolation related to mania: Social isolation may be a concern, but the immediate priority is addressing the risk for violence, as it poses a more significant threat to the client and others during a manic episode.

A. Orientation B. Affect C. Perception D. Mood

Correct Answer is A

Explanation

Orientation: When a nurse asks a client to identify their name, date, residential address, and situation, they are assessing the client's orientation. Orientation refers to an individual's awareness of time, place, person, and situation.

B. Affect: Affect refers to the observable expression of emotions. It involves the client's emotional tone, such as being happy, sad, angry, or flat. It is not directly assessed by asking about personal information.

C. Perception: Perception involves the way individuals interpret and make sense of sensory information. Asking about personal information is more related to orientation than perception.

D. Mood: Mood refers to a more sustained emotional state. It is not directly assessed by asking for specific personal information about the current situation or location.

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For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of Haloperidol is whether

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly admitted client diagnosed with Bipolar I is experiencing an acute manic episode. Which nursing diagnosis is a priority?

Correct Answer is B

Explanation

What is being assessed when a nurse asks a client to identify name date, residential address, and situation?

Correct Answer is A

Explanation

Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder?

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety?

A client diagnosed with schizophrenia states, Can't you hear him? Its the devil. He's telling me I'm going to hell. Which is the most appropriate nursing reply?

A nurse is caring for a client who has a mental illness and is without housing. The nurse should identify that which of the following interprofessional team members can help the client find housing?

A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

A charge nurse is instructing a newly licensed nurse about mental health disorders. Which of the following statements by the nurse indicates an understanding of mental health disorders?

How does a democratic form of self-government in the milieu contribute to client therapy?