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

Choice A rationale:

Requesting that the provider renew the prescription for restraints every 8 hours is not the best approach. The nurse should follow the facility's policies and protocols for the use of restraints, and these policies typically require that the provider assess the client within a specific timeframe after applying restraints. The provider's assessment should occur promptly to determine the client's continued need for restraints and to address the client's safety and well-being.

Choice C rationale:

Evaluating the client hourly while the restraints are applied is not sufficient. While it's important to monitor the client, especially in terms of circulation and comfort, the provider's assessment should take place within a shorter timeframe, typically within one hour after applying the restraints. Hourly evaluations alone may not be timely enough to address the client's condition and the necessity of the restraints.

Choice D rationale:

Obtaining a prescription for restraints on an as-needed basis is not an appropriate approach. Restraints should only be used when necessary to ensure the safety of the client or others, and their use should be based on a specific assessment by the provider. Using restraints on an as-needed basis without a clear prescription can lead to ethical and legal issues and should be avoided.

A. Explain implied consent to the client's family. B. Contact the facility social worker to obtain the consent. C. Request that the client's guardian sign the consent. D. Ask the charge nurse to obtain informed consent.

Correct Answer is C

Explanation

Choice A rationale:

Explaining implied consent to the client's family is not the appropriate action in this situation. Implied consent typically refers to situations where consent is assumed due to the client's actions or circumstances, but it is not applicable when a client has been declared legally incompetent. The nurse should seek consent from a legally authorized representative, such as a guardian, in this case.

Choice B rationale:

Contacting the facility social worker is a good step to take when dealing with complex legal and ethical situations. However, the nurse's primary responsibility is to ensure that the client's legally authorized representative provides informed consent. This means that the client's guardian should be the one to sign the consent form, rather than the social worker.

Choice D rationale:

Asking the charge nurse to obtain informed consent is not the appropriate action because obtaining consent is typically the responsibility of the healthcare provider or a legally authorized representative. The charge nurse may not have the legal authority to provide informed consent on behalf of the client.

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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?