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 A

Explanation

Rationale

A. This action helps maintain adequate cerebral perfusion pressure and venous drainage, which is important in suspected stroke cases. It supports optimal cerebral blood flow and reduces the risk of increased intracranial pressure. However, it's not the immediate intervention required for this client. The primary focus initially is on diagnostic evaluation and stabilization.

B. Elevating the joints on the affected side can help reduce dependent edema and promote circulation. This intervention is part of ongoing nursing care to prevent complications like deep vein thrombosis (DVT) in stroke patients who may have reduced mobility. While important, it is not the immediate priority in the acute phase of management.

C. Gathering a focused history is crucial to understanding potential causes or exacerbating factors contributing to the client's symptoms While important, it is not the immediate priority in the acute phase of management.

D. Intermittent pneumatic compression devices (IPC) are used to prevent deep vein thrombosis (DVT) by enhancing venous return and preventing stasis in the lower extremities. While DVT prevention is important in stroke patients, it is not the immediate intervention required for the client's acute neurological symptoms.

Correct Answer is ["21"]

Explanation

To calculate the flow rate in gtt/min, you can use the formula: (Volume in mL * Drop factor) / Time in
minutes.

For 1 L of lactated Ringer's IV, which is 1000 mL, to be infused over 12 hours, with an IV administration set that delivers 15 gtt/mL, the calculation would be: (1000 mL * 15 gtt/mL) / (12 hours * 60 minutes/hour).

This simplifies to (15000 gtt) / (720 minutes), which equals approximately 20.83 gtt/min.

Therefore, the nurse should regulate the infusion to 21 gtt/min, rounding to the nearest whole
number.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["21"]

Explanation

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