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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A: Consult the client.
Choice A rationale:
Consulting the client is the most appropriate action to respect their privacy and autonomy. It ensures that the client has control over their health information and consents to any disclosures.
Choice B rationale:
Consulting the client's family is not appropriate without the client's explicit permission, as it may violate the client's right to confidentiality.
Choice C rationale:
Contacting the provider may be helpful for clinical guidance, but they cannot disclose the client's health information without the client's consent.
Choice D rationale:
Contacting the facility legal department would be necessary in specific legal situations, but the first step should be to involve the client in the decision-making process to respect their rights.
Correct Answer is D
Explanation
Choice A rationale:
Hemoglobin levels at 16 g/dL are within the normal range for an adult, so there is no need to report this result to the provider.
Choice B rationale:
A white blood cell (WBC) count of 8,000/mm3 is within the normal range, and there is no need to report this result to the provider.
Choice C rationale:
An RBC count of 4.9 million/mm² is within the normal range for adults, so it does not require reporting to the provider.
Choice D rationale:
A platelet count of 100,000/mm3 is below the normal range (typically 150,000-450,000/mm3). This lower platelet count can increase the risk of bleeding and may be associated with clonazepam use. Therefore, it should be reported to the provider for further evaluation and potential adjustment of the medication.
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