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 ["A","B","D","F","I"]

Explanation

A. The blood alcohol level of 510 mg/dL indicates severe intoxication and requires monitoring for potential complications, such as respiratory depression or alcohol withdrawal.

B. The client's recent loss of both parents is significant and may contribute to the relapse of alcohol use disorder. It warrants further assessment of the client's coping mechanisms and emotional state.
C. Smoking history:

While the client's smoking history may be relevant to their overall health, it is not a priority for follow-up in this scenario where the client's alcohol intoxication and potential withdrawal symptoms are the primary concerns.
D. The client's recent consumption of alcohol, as reported by the family member, is crucial information for assessing the risk of alcohol withdrawal and planning appropriate
interventions.

E. Cardiac assessment:
The client's vital signs indicate normal sinus rhythm and stable blood pressure, suggesting no acute cardiac issues at present. Given the focus on alcohol intoxication and potential withdrawal, a comprehensive cardiac assessment is not immediately warranted.
F. The neurological assessment is essential to monitor for signs of alcohol withdrawal, such as tremors, hallucinations, or seizures, given the client's history of alcohol use disorder and current intoxication.
G. Genitourinary assessment:

While assessing the genitourinary system is important in a comprehensive nursing assessment, there are no indications in the provided information to suggest acute genitourinary issues requiring immediate follow-up. The client's current symptoms and history primarily suggest alcohol intoxication and potential withdrawal.
H. Respiratory assessment:

The client's respiratory assessment indicates clear lung sounds and adequate oxygen saturation, suggesting no acute respiratory distress at the time of admission. While
respiratory status should be monitored, it is not a priority for immediate follow-up compared to the client's alcohol intoxication and potential withdrawal.
I. Assessing the gastrointestinal system is important to evaluate the client's nutritional status, assess for signs of liver disease or other gastrointestinal complications associated with alcohol use disorder, especially considering the reported weight loss and minimal appetite.

A. Tell the client he cannot refuse the treatment because he was involuntarily committed. B. Ask the client's family to encourage the client to receive ECT. C. Document the client's refusal of the treatment in the medical record. D. Inform the client that ECT does not require client consent.

Correct Answer is C

Explanation

A. Coercing the client into treatment violates the client's autonomy and rights. Involuntary commitment does not mean the client loses the right to refuse treatment.
B. Involving the client's family without their consent or participation in decision-making may not be appropriate and could breach confidentiality.
C. Documenting the client's refusal of treatment ensures that the decision is appropriately recorded in the medical record and facilitates communication among the healthcare team members. It also protects the client's autonomy and legal rights.
D. Informing the client that ECT does not require consent is incorrect. While laws regarding involuntary treatment vary by jurisdiction, clients generally have the right to refuse treatment, even if they are involuntarily committed.

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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

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["A","B","D","F","I"]

Explanation

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Correct Answer is C

Explanation

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