A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider?

Banana slices are soft, easy to chew, and can be picked up by the toddler’s fingers, which promotes independence in eating. According to the CDC, foods that toddlers should avoid include:

• Added sugars and no-calorie sweeteners, such as sugar-sweetened and diet drinks
• High-salt foods, such as canned foods, processed meats, frozen dinners, fast food, and junk food
• Unpasteurized juice, milk, yogurt, or cheese
• Foods that may cause choking, such as hard or crunchy foods, sticky foods, stringy cheese, and foods that are not cut up into small pieces

Choice A is wrong because popcorn is a choking hazard for toddlers.

It is hard, crunchy, and can get stuck in the airway. The NHS advises not to give whole nuts and peanuts to children under 5 years old.

Choice B is wrong because grapes are also a choking hazard for toddlers.

They are round, slippery, and can block the airway. The NHS recommends cutting grapes into quarters before giving them to young children.

Choice D is wrong because hot dogs are high in salt and can cause choking if not cut up into small pieces. The Extension warns against giving hot dogs to young toddlers.

The correct answer is c. Document the client's behavior prior to being placed in seclusion.

Rationale for Choice a. Discuss with the client his inappropriate behavior prior to seclusion:

While discussing the client's behavior may be helpful in some situations, it is not the most appropriate action to take immediately before seclusion. This is because:

1. Escalation:Attempting to discuss behavior in the moments leading up to seclusion can potentially escalate the situation and further jeopardize the safety of the client,staff,and other patients.
2. Impaired Insight:Clients requiring seclusion may have limited ability to engage in rational discussion due to heightened emotional states,cognitive impairment,or acute mental illness.
3. Limited Receptiveness:The client may not be receptive to feedback or discussion while in a state of crisis,potentially leading to frustration and further agitation.

Rationale for Choice b. Offer fluids every 2 hr.:

Offering fluids is a basic nursing intervention, but it is not the priority action in this scenario. The primary focus at this time is ensuring safety and managing the acute behavioral crisis. Addressing hydration needs can be attended to after the client is safely placed in seclusion.

Rationale for Choice d. Assess the client’s behavior once every hour.:

Regular assessment is crucial, but hourly assessment is not frequent enough in this situation. Clients in seclusion require close monitoring and assessment at more frequent intervals to ensure their safety and well-being, as well as to evaluate the effectiveness of the seclusion intervention.

Rationale for Choice c. Document the client’s behavior prior to being placed in seclusion.:

This is the most appropriate action for the nurse to take for the following reasons:

1. Legal and Ethical Requirements:Accurate documentation of the client's behavior prior to seclusion is essential for legal and ethical reasons.It serves as a record of the rationale for seclusion,supporting the decision-making process and ensuring adherence to best practices and patient rights.
2. Assessment and Intervention Planning:Detailed documentation provides valuable information for ongoing assessment and intervention planning.It allows healthcare professionals to track the client's progress,identify patterns in behavior,and make informed decisions about the continuation or discontinuation of seclusion.
3. Communication and Collaboration:Comprehensive documentation facilitates effective communication and collaboration among the healthcare team members,ensuring continuity of care and promoting a holistic approach to the client's treatment.
4. Evaluation and Quality Improvement:Accurate documentation enables evaluation of the effectiveness of seclusion interventions and contributes to quality improvement initiatives within the healthcare setting.