A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?
Obtain the provider's prescription within 60 min.
Document the client's behavior every 15 min.
Monitor the client's vital signs every 4 hr.
Offer the client food and fluids every 2 hr.
The Correct Answer is A
The nurse should obtain a provider's prescription for seclusion within 60 min of placing the client in seclusion, according to the standards of care for psychiatric-mental health nursing. The other actions are also important, but not as urgent as obtaining a prescription.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Significant weight loss. This finding indicates a risk for malnutrition, dehydration, and electrolyte imbalance, which can affect the client's physical and mental health. The other findings are also important to report, but they are not as urgent as weight loss.
Correct Answer is D
Explanation
During the orientation phase, the nurse should introduce herself and the group members, explain the purpose and goals of the group, and create a trusting and respectful atmosphere. Maintaining focus, encouraging problem-solving, and managing conflict are actions that belong to the working phase of group development.
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