A nurse in orientation is rotating to a psychiatric unit where they observe a client in seclusion. Which of the following statements by the nurse’s preceptor best explains the use of seclusion on a unit?
The reduced sensory input allows the client to regain control.
Clients are encouraged to communicate with others.
Clients are forced to be responsible for themselves.
The unit can be managed with fewer staff.
The Correct Answer is A
Choice A Reason:
Seclusion is used in psychiatric settings primarily to manage patients who are exhibiting aggressive or severely disturbed behavior. The reduced sensory input in a seclusion room helps the patient to regain control over their emotions and behavior by minimizing external stimuli that could exacerbate their condition. This controlled environment can be crucial in preventing harm to the patient and others, and it allows the patient to calm down in a safe space. The goal is to provide a therapeutic setting that aids in the patient’s recovery and stabilization.
Choice B Reason:
While communication is an essential part of psychiatric care, seclusion is not intended to encourage interaction with others. In fact, seclusion is used when a patient needs to be isolated to prevent harm to themselves or others. Encouraging communication is more appropriate in other therapeutic settings where the patient is stable and can engage safely with others. Therefore, this statement does not accurately explain the purpose of seclusion.
Choice C Reason:
Forcing clients to be responsible for themselves is not the primary goal of seclusion. Seclusion is a measure taken to ensure safety and to help the patient regain control over their behavior in a controlled environment. Responsibility and self-management are important aspects of psychiatric treatment, but they are typically addressed through other therapeutic interventions and not through seclusion. Thus, this statement is not an accurate explanation of the use of seclusion.
Choice D Reason:
Managing the unit with fewer staff is not a valid reason for using seclusion. The primary purpose of seclusion is to ensure the safety of the patient and others, not to reduce staffing needs. In fact, the use of seclusion requires careful monitoring and adherence to strict protocols, which can actually increase the need for staff attention. Therefore, this statement does not correctly explain the rationale behind the use of seclusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
To calculate the infusion rate in drops per minute:
- Identify the total volume to be infused: 125 mL
- Identify the total time for infusion: 1 hour (which is 60 minutes)
- Identify the drop factor: 60 gtts/mL
Step 1: Calculate the infusion rate in mL per minute.
- Volume (mL) ÷ Time (minutes)
- 125 mL ÷ 60 minutes = 2.0833 mL per minute
Step 2: Calculate the infusion rate in drops per minute.
- Infusion rate (mL per minute) × Drop factor (gtts/mL)
- 2.0833 mL per minute × 60 gtts/mL = 125 gtts per minute
The drug will infuse at 125 drops per minute.
Correct Answer is D
Explanation
Choice A Reason:
Pseudo-Parkinsonian side effects, also known as drug-induced parkinsonism, can occur with the use of antipsychotic medications like haloperidol. These side effects include symptoms such as rigidity, bradykinesia, tremor, and postural instability. However, the description of the client’s neck arched sharply backward is more indicative of an acute dystonic reaction rather than pseudo-Parkinsonian side effects. Pseudo-Parkinsonian symptoms typically develop more gradually and do not present with such dramatic posturing.
Choice B Reason:
While some side effects of haloperidol can be temporary and may disappear after several days, the acute dystonic reaction described in the scenario requires immediate intervention. Acute dystonic reactions are characterized by sudden, severe muscle contractions that can be painful and potentially dangerous if they involve the airway. Therefore, it is crucial to address this reaction promptly rather than waiting for it to resolve on its own.
Choice C Reason:
Increasing the dosage of haloperidol in response to the described symptoms would likely exacerbate the situation. The client’s symptoms are not indicative of worsening psychotic behavior but rather an adverse reaction to the medication. Increasing the dosage could lead to more severe side effects and complications. The appropriate response is to treat the acute dystonic reaction and reassess the medication regimen.
Choice D Reason:
An acute dystonic reaction is a known side effect of antipsychotic medications like haloperidol. It involves sudden, severe muscle contractions, often affecting the neck, face, and back. This reaction can be distressing and requires immediate treatment with anticholinergic medications such as benztropine or diphenhydramine. Prompt intervention can relieve the symptoms and prevent further complications.
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