As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.
Which interventions should you perform?

Choice A rationale

While securing the room with padded walls and minimal furnishings is an important aspect of seclusion, it is not the most important intervention immediately after seclusion. The safety of the client is paramount, and observing for extrapyramidal symptoms, such as dystonia, is crucial as haloperidol, an antipsychotic medication known to have the potential for causing extrapyramidal side effects, was administered.

Choice B rationale

Releasing the client as soon as composure is regained is not the most important intervention. The client’s mental and physical health needs to be continuously monitored, especially for side effects of the medication administered.

Choice C rationale

Providing one-on-one observation at all times is important, but it is not the most important intervention immediately after seclusion. The priority is to monitor for any adverse effects of the medication administered.

Choice D 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.

Choice A rationale

While substituting natural fruit juices for carbonated drinks can be a healthy dietary change, it is not directly related to the patient’s reported symptoms of severe pain and inability to bear weight on the right ankle.

Choice B rationale

Avoiding the consumption of wine, beer, and coffee can have various health benefits, but it is not directly related to the patient’s current symptoms. Furthermore, there is no indication in the patient’s history that these beverages are contributing to the patient’s condition.

Choice C rationale

Using an electric heating pad when pain is at its worst can provide temporary relief, but it does not address the underlying issue causing the pain. Additionally, heat therapy is not typically recommended for acute gout attacks, which could be a potential cause of the patient’s symptoms given their history of gouty arthritis.

Choice D rationale

Encouraging active range of motion can help to limit stiffness and improve joint function, which could potentially alleviate the patient’s pain and improve their ability to bear weight on the right ankle. This advice is relevant to the patient’s symptoms and medical history.