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.

Offer the client food and fluids every 2 hr.

Monitor the client's vital signs every 4 hr.

Obtain the provider's prescription within 60 min.

Answer and Explanation

The Correct Answer is A

Choice B rationale:

Offering the client food and fluids every 2 hours is not the most appropriate action in this situation. When a client has been placed in seclusion due to physical aggression, their safety and the safety of the staff must be the top priority. It is essential to monitor the client's behavior and document it regularly to ensure they do not pose a threat to themselves or others.

Choice C rationale:

Monitoring the client's vital signs every 4 hours is not the highest priority when a client has become physically aggressive and is placed in seclusion. Vital sign monitoring is important for the overall assessment of a client's health, but it may not address the immediate safety concerns associated with aggressive behavior. Regular observation and documentation of the client's behavior are more critical in this situation.

Choice D rationale:

Obtaining the provider's prescription within 60 minutes is an important step, but it is not the most immediate priority. While it is essential to have a healthcare provider's order for seclusion, the safety of the client and staff takes precedence. Documenting the client's behavior every 15 minutes allows for ongoing assessment of their condition and ensures their well-being during the time leading up to obtaining the provider's order.

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Correct Answer is B

Explanation

A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? The correct answer is choice B. Notify the client about designated times for meals.

Choice A rationale:

Weighing the client weekly for the first month is not an appropriate intervention in the initial care plan for a client with anorexia nervosa. While monitoring weight is essential, weekly weigh-ins may contribute to anxiety and distress in clients with eating disorders. The frequency of weigh-ins and the timing should be individualized based on the client's specific needs.

Choice B rationale:

Notifying the client about designated times for meals is a crucial intervention in the care plan for someone with anorexia nervosa. Establishing a structured meal schedule is important in promoting regular eating habits and preventing excessive exercise or other behaviors related to the disorder. Providing consistency in meal times can help the client regain control over their eating patterns.

Choice C rationale:

Negotiating with the client on how much weight she should gain each week is not a recommended approach in the initial stages of treatment for anorexia nervosa. Clients with this disorder often have distorted body image and unrealistic weight goals. It's important to set safe and appropriate weight gain goals based on the client's individual needs and in collaboration with a healthcare team, rather than negotiating arbitrary targets with the client.

Choice D rationale:

Decreasing the client's daily intake of fiber is not a suitable intervention in the care plan for anorexia nervosa. While dietary modifications may be necessary, reducing fiber intake can lead to constipation and other digestive issues. Any dietary changes should be made under the guidance of a registered dietitian or healthcare provider and should aim to restore a healthy and balanced diet.

A. Administer a dose of alprazolam to the client. B. Encourage the client to describe their feelings in a journal. C. Encourage the client to watch television as a distraction. D. Administer a dose of atomoxetine to the client.

Correct Answer is A

Explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse in an in-patient facility is caring for a client who has an anxiety disorder.Which of the following actions should the nurse take while the client is experiencing an acute panic attack?

Correct Answer is A

Explanation

A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client.Which of the following actions should the nurse take?

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A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?

A nurse is assessing a client who repeatedly falsifies psychological symptoms to assume the role of a sick person.What statement is commonly associated with this behavior?

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