A nurse in a mental health clinic is assessing a client who has dependent personality disorder. Which of the following findings should the nurse expect?

Choice A reason: The provider must assess the client within 1 hour of initiating seclusion, not 8 hours. Delaying assessment violates safety protocols and legal requirements for restraint and seclusion use.

Choice B reason: Seclusion cannot be discontinued solely based on client request. It must be discontinued when the client demonstrates behavioral control and no longer poses a risk to themselves or others.

Choice C reason: Documenting the client’s behavior every 15 minutes is the correct action. Continuous monitoring ensures safety, evaluates effectiveness of seclusion, and provides legal documentation. This practice aligns with facility protocols and patient rights.

Choice D reason: Requesting a PRN prescription for future seclusion is inappropriate. Seclusion is a last-resort intervention and cannot be prescribed in advance. Each episode must be justified by current behavior and assessed individually.

Choice A reason: Identifying the client’s feelings underlying the delusions is therapeutic. Delusions often mask fear, anxiety, or insecurity. By focusing on the emotions rather than the false belief, the nurse validates the client’s experience without reinforcing the delusion. This approach builds trust and supports emotional regulation.

Choice B reason: Telling the client that the delusion is not real is ineffective and can increase defensiveness. Clients with schizophrenia often lack insight, and direct confrontation may escalate agitation or mistrust.

Choice C reason: Reinforcing the delusion is harmful. It strengthens false beliefs and impedes recovery. Nurses must avoid validating delusional content while still supporting the client’s emotional needs.

Choice D reason: Helping the client ignore events that trigger delusions is unrealistic. Triggers cannot always be avoided, and ignoring them does not teach coping strategies. Instead, nurses should help clients develop grounding techniques and reality-based coping skills.