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 D

Explanation

A. This statement reflects a realistic acknowledgment of the grieving process and does not necessarily indicate clinical depression.
B. Expressing dependence on family support is a common coping mechanism during grief and does not necessarily indicate clinical depression.
C. Feelings of anger are common during the grieving process and do not necessarily indicate clinical depression.
D. Feeling numb or anhedonic, the inability to experience pleasure, is a symptom commonly associated with clinical depression and should be reported to the provider for further evaluation and intervention.

A. "Ask a family member to check the locks for you at night." B. "Keep a journal of how often you check the locks each night." C. "Focus on abdominal breathing whenever you go to check the locks." D. "Snap a rubber band on your wrist when you think about checking the locks."

Correct Answer is D

Explanation

A. Asking a family member to check the locks for the client may alleviate immediate anxiety but does not address the underlying obsessive-compulsive behavior or provide coping mechanisms for the client to manage their symptoms independently.
B. Keeping a journal of checking behaviors may be part of exposure and response prevention therapy but does not directly address the intrusive thoughts associated with obsessive- compulsive disorder in the moment.
C. Focusing on abdominal breathing is a relaxation technique that may help reduce overall anxiety but does not specifically target the intrusive thoughts associated with obsessive- compulsive disorder.
D. Using a rubber band to snap on the wrist when the client thinks about checking the locks is a form of aversion therapy, which is a component of thought stopping technique. This technique helps interrupt and redirect the obsessive thoughts, promoting awareness and control over compulsive behaviors.

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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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