A nurse is caring for a client who requires seclusion to prevent harm to others on the unit.
Which of the following is an appropriate action for the nurse to take?
Discuss with the client his inappropriate behavior prior to seclusion
Offer fluids every 2 hr.
Document the client’s behavior prior to being placed in seclusion.
Assess the client’s behavior once every hour.
The Correct Answer is C
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:
- 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.
- 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.
- 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:
- 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.
- 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.
- 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.
- Evaluation and Quality Improvement: Accurate documentation enables evaluation of the effectiveness of seclusion interventions and contributes to quality improvement initiatives within the healthcare setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. The nurse should compare new prescriptions with the list of medications the client reports. This is part of the medication reconciliation process, which is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
Choice B is wrong because the nurse should not encourage the client to make his own list after he returns to his home. The nurse should provide the client with an updated and accurate list of medications before discharge and instruct the client to keep it with him at all times.
Choice C is wrong because the nurse should not include any adverse effects of the medications the client might develop. The nurse should include any known allergies or adverse reactions the client has experienced in the past, but not potential adverse effects that have not occurred.
Choice D is wrong because the nurse should not exclude nutritional supplements from the list of medications the client reports. The nurse should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions in the medication reconciliation process.
Some of these products may interact with prescribed medications or affect laboratory results.
Correct Answer is D
Explanation
Choice A reason
Abdomen area is not appropriate: Assessing skin turgor on the abdomen is not commonly performed. The abdomen may not be the most accurate site for assessing skin turgor, especially in older adults, as it can be influenced by factors such as body fat distribution.
Choice B reason:
Shoulder are is not appropriate: The shoulder is not a typical site for assessing skin turgor. It is generally not used for this purpose, as it may not provide reliable results
Choice C reason:
Stomach is not the correct answer.: Assessing skin turgor on the stomach is also not commonly performed. The abdomen or stomach may not be the most accurate site for assessing skin turgor, especially in older adults.
Choice D reason
When assessing skin turgor in an older adult client, the nurse should lift the skin on the neck to evaluate its elasticity and hydration status. Skin turgor is a measure of skin's elasticity and is commonly used as an indicator of hydration in both adults and older adults.
To assess skin turgor, the nurse will gently pinch a small amount of skin on the back of the client's hand or the front of the chest (sternum). However, since the options listed do not include these areas, the closest alternative for an older adult would be the neck.
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