A nurse in an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?
An adolescent client who throws objects at other clients
An older adult client who is manic and crying due to overstimulation
A school-age client who attempts to repeatedly bite staff
An adult client following a suicide attempt
The Correct Answer is D
A. An adolescent client who throws objects at other clients:
Explanation: Seclusion is contraindicated for this client due to safety concerns. The behavior of throwing objects at others indicates a potential danger to both the client and others in a confined space. Placing the client in seclusion could escalate the situation and potentially lead to further harm.
B. An older adult client who is manic and crying due to overstimulation:
Explanation: Seclusion might be contraindicated for this client as well. Older adults experiencing manic behavior and emotional distress could be further traumatized by seclusion. Alternatives like providing a calm and soothing environment, along with appropriate medications, might be more beneficial for this client.
C. A school-age client who attempts to repeatedly bite staff:
Explanation: Seclusion is a potential option for this client. The repeated attempts to bite staff pose a risk of physical harm to both the client and staff members. Seclusion might be used as a last resort to ensure the safety of everyone involved.
D. An adult client following a suicide attempt:
Explanation: Seclusion is generally contraindicated for clients who have attempted suicide. Placing them in isolation can worsen feelings of despair and isolation, potentially increasing the risk of self-harm or suicide. These clients require close monitoring, support, and therapeutic interventions to address the underlying issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Maturational crisis:
This type of crisis arises from normal life transitions, such as entering a new stage of development (adolescence, midlife crisis, etc.). It involves a struggle to adapt to new roles and responsibilities. The client's situation does involve a life transition due to the death of his wife, but the sudden nature of the event and the resulting distress suggest a situational crisis.
B) Adventitious crisis:
Adventitious crises are caused by extraordinary events that are external to the individual's usual experience, such as natural disasters, accidents, or crimes. While the sudden death of the client's wife is an unexpected and tragic event, it's not an adventitious crisis because it involves personal loss rather than a large-scale or external event.
C) Developmental crisis:
Developmental crises are associated with specific stages of life and the challenges and changes that come with them. This crisis doesn't seem to fit the developmental category as it is more tied to the specific event of the wife's sudden death.
D) Situational crisis
Explanation:
A situational crisis is a type of crisis that arises from a specific event or situation that disrupts an individual's normal functioning and coping abilities. In this case, the sudden death of the client's wife is the triggering event that has led to his feeling paralyzed and overwhelmed in his ability to cope with work and family responsibilities. Situational crises are often unexpected and can lead to a temporary state of disorganization and distress.
Correct Answer is D
Explanation
While preventing injury is important, it is not the highest priority when the client's respiratory and neurological functions are compromised. Managing the client's breathing takes precedence.
B. Applying a cooling blanket.
While hyperthermia (high fever) is a symptom of serotonin syndrome, the immediate concern is ensuring the client's breathing and neurological stability. Cooling measures can be beneficial, but they come after addressing the more critical issues.
C. Administering an anticonvulsant.
While anticonvulsants might be used to control seizures, preparing for artificial ventilation takes priority, as the client's airway and oxygenation must be secured before addressing other symptoms.
D. Preparing for artificial ventilation.
Explanation: Serotonin syndrome is a potentially life-threatening condition caused by an excess of serotonin in the body, often resulting from interactions between medications that affect serotonin levels. Severe manifestations of serotonin syndrome can include high fever, muscle rigidity, agitation, seizures, and even coma. In cases of severe serotonin syndrome, the client's neurological and respiratory functions can be compromised, making it crucial to ensure adequate ventilation and oxygenation.
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