A client is admitted with bipolar disorder, manic psychosis. The client is placed in seclusion after unsuccessful attempts by staff at deescalating the client 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 IM STAT prior to seclusion. Which intervention is most important for the nurse to implement immediately after seclusion?

Secure the room with padded walls and minimal furnishings.

Provide one-on-one observation at all times.

Release the client as soon as composure is regained.

Observe for extrapyramidal symptoms, such as dystonia.

Answer and Explanation

The Correct Answer is D

Rationale

A. While ensuring the room is secure and providing one-on-one observation are also important, the immediate concern after administering haloperidol is the potential for these side effects.

B. Continuous observation is crucial to monitor the client's behavior, mood, and safety while in seclusion. This allows the nurse to intervene promptly. However, monitoring should be specific

C. Seclusion is not intended as a punishment but as a therapeutic intervention to protect the client and others from harm during acute psychiatric episodes. The decision to release the client should be based on clinical assessment

D. Haloperidol is an antipsychotic medication that can cause extrapyramidal symptoms (EPS), including dystonia (muscle spasms). Monitoring for EPS is essential after administering haloperidol to ensure early detection and treatment, which may involve administering anticholinergic medications if EPS occurs.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

After listening to the client's symptoms, the nurse realizes that she likely has acute stress disorderrelated to traumatic stress

Acute Stress Disorder: This diagnosis fits because the client is experiencing significant distress and anxiety related to the traumatic event (her house collapsing during a hurricane). Acute stress disorder is characterized by intrusive thoughts, nightmares, flashbacks, and avoidance behaviors following exposure to a traumatic event. The client's symptoms of persistent thoughts about the event, difficulty sleeping due to these thoughts, and feeling unable to return to her previous emotional state ("funk") are indicative of acute stress disorder.

Traumatic Stress: This describes the source of the client's symptoms. The collapse of her house during a hurricane is a traumatic event that has triggered her acute stress disorder symptoms. Traumatic stress refers to the psychological and emotional response to a deeply distressing or disturbing event.

A. Apply ice then a warm compress to the IV site. B. Discontinue the IV site after inserting a new access. C. Redress the IV site while assessing for redness. D. Review the medical record for the date of insertion.

Correct Answer is B

Explanation

Rationale

A. Applying ice or a warm compress without assessing the site could potentially worsen any underlying issue.

B. The appropriate intervention would be to discontinue the IV site after ensuring a new access is established. This is because continuing to use a painful IV site can lead to complications such as infiltration or phlebitis.

C. Redressing the site without assessment does not address the client's complaint of pain.

D. Checking the medical record provides information about when the IV was inserted, which can be important for assessing the site's viability and expected duration. However, it doesn't address the immediate concern of the client's pain at the site or refusal of a flush.

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Naxlex Comprehensive Predictor Exams

Exhibits Select from the options to complete the sentence. After listening to the client's symptoms, the nurse realizes that she likely has dropdown related to dropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Correct Answer is B

Explanation

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

Exhibits The nurse starts the albuterol nebulizer as prescribed. Which should the nurse assess after the albuterol nebulizer treatment is complete? Select all that apply.

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, 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?

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?