A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

Document the client's behavior every 15 min.

Obtain the provider's prescription within 60 min.

Monitor the client's vital signs every 4 hr.

Offer the client food and fluids every 2 hr.

Answer and Explanation

The Correct Answer is A

A.   Documenting the client's behavior every 15 minutes is essential for monitoring the client's condition, response to seclusion, and any changes in behavior or status.
B.   Obtaining the provider's prescription within 60 minutes may be necessary but does not address immediate nursing actions required after placing the client in seclusion.
C.   Monitoring vital signs every 4 hours is not specific to managing a client in seclusion and may not provide timely information about the client's condition or response to seclusion.
D.   Offering food and fluids every 2 hours is important for meeting the client's physiological needs but may not be appropriate immediately after placing the client in seclusion, depending on the circumstances and facility policies.

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Correct Answer is B

Explanation

A. Walking the dog daily can contribute positively to the client's recovery by promoting physical activity and potentially reducing stress.
B. The loss of social support due to the best friend moving away can increase stress and negatively impact the client's recovery.
C. Exercising in the morning can also contribute positively to recovery by promoting physical health and potentially reducing stress.
D. Stopping drinking coffee may have various effects on the client's health but is not directly related to recovery from coronary artery bypass surgery unless it exacerbates other issues such as anxiety or withdrawal symptoms.

A. The client develops an inability to concentrate. B. The client exhibits an inflated sense of self. C. The client begins sleeping more than usual. D. The client increases participation in social activities.

Correct Answer is A

Explanation

A. Inability to concentrate is a common early sign of relapse in schizophrenia. It can indicate worsening symptoms and difficulty in maintaining focus and attention.
B. An inflated sense of self is not typically associated with relapse in schizophrenia. It may be a symptom of other psychiatric disorders, such as bipolar disorder or narcissistic personality disorder.
C. Increased sleeping can be a symptom of depression but is not specific to schizophrenia relapse.
D. Increased participation in social activities is not typically associated with relapse in schizophrenia. It may indicate improvement in social functioning or adaptation to the illness.

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Body system	Findings
Neurological	Impaired cognition

	Insomnia Seizures
Cardiovascular	Increased blood pressure Increased heart rate Diaphoresis
Gastrointestinal	Lack of appetite Vomiting
Musculoskeletal	Malaise Tremulousness

A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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