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: “We can review some information to help you select a safe alternative practitioner.” This statement shows respect for the client’s interest in alternative therapies and offers guidance on how to choose a reliable and qualified provider. Alternative therapies can provide some benefits for people with rheumatoid arthritis, such as reducing pain, inflammation, and stiffness, but they should be used as a complement to conventional treatments and not as a substitute.
Choice B is wrong because it implies that the client has no role in deciding their own treatment plan and that alternative therapies are not worth considering.
This may discourage the client from sharing their preferences and concerns with the provider.
Choice C is wrong because it suggests that online support groups are a reliable source of information about alternative remedies, which may not be true.
Online sources may contain inaccurate, misleading, or harmful information that could jeopardize the client’s health and safety.
Choice D is wrong because it encourages the client to try any therapy that fits their personal belief system, without considering the evidence, effectiveness, or potential risks of such therapies. Some alternative therapies may interact with medications, cause side effects, or worsen the condition.
Normal ranges for rheumatoid arthritis are not applicable in this question, as it is not asking about laboratory values or disease activity measures. However, some common tests used to diagnose and monitor rheumatoid arthritis include erythrocyte sedimentation rate (ESR), Creactive protein (CRP), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, and joint ultrasound or X-ray.
The normal ranges for these tests may vary depending on the laboratory and the method used.
Correct Answer is D
Explanation
Hypertonicity is a sign of increased muscle tone and stiffness, which can indicate that the newborn is experiencing withdrawal from methadone exposure in utero. Methadone is an opioid medication that can cross the placenta and cause neonatal abstinence syndrome (NAS) in the newborn.
Choice A, acrocyanosis, is wrong because it is a normal finding in newborns.
Acrocyanosis is a bluish discoloration of the hands and feet due to immature peripheral circulation. It usually resolves within the first 24 to 48 hours of life.
Choice B, bradycardia, is wrong because it is not a typical sign of withdrawal.
Bradycardia is a slow heart rate, usually less than 100 beats per minute in newborns. It can be caused by hypoxia, hypothermia, hypoglycemia, or vagal stimulation.
Choice C, bulging fontanels, is wrong because it is a sign of increased intracranial pressure, not withdrawal. Bulging fontanels can be caused by meningitis, hydrocephalus, or hemorrhage.
Normal ranges for newborn vital signs are as follows:
- Heart rate: 120 to 160 beats per minute
- Respiratory rate: 30 to 60 breaths per minute
- Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
- Blood pressure: 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic
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