A nurse is caring for an adult client who is experiencing mania and is placed in seclusion due to escalating behavior. Which of the following actions should the nurse take?
Request that the provider assess the client within 8 hr.
Discontinue the seclusion if the client requests it.
Document the client's behavior every 15 min while in seclusion.
Request a PRN prescription for future seclusion.
The Correct Answer is C
Choice A reason: The provider must assess the client within 1 hour of initiating seclusion, not 8 hours. Delaying assessment violates safety protocols and legal requirements for restraint and seclusion use.
Choice B reason: Seclusion cannot be discontinued solely based on client request. It must be discontinued when the client demonstrates behavioral control and no longer poses a risk to themselves or others.
Choice C reason: Documenting the client’s behavior every 15 minutes is the correct action. Continuous monitoring ensures safety, evaluates effectiveness of seclusion, and provides legal documentation. This practice aligns with facility protocols and patient rights.
Choice D reason: Requesting a PRN prescription for future seclusion is inappropriate. Seclusion is a last-resort intervention and cannot be prescribed in advance. Each episode must be justified by current behavior and assessed individually.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Clients admitted involuntarily still retain the right to refuse medications unless a court order or emergency situation overrides this right. This statement is incorrect.
Choice B reason: Involuntary admission does not automatically mean a client is incompetent. Competency must be legally determined by a court, not assumed based on admission status.
Choice C reason: Restraints cannot be prescribed on an as-needed basis. They require a specific, time-limited order and must be used only when absolutely necessary to protect the client or others.
Choice D reason: Providers have a duty to warn identifiable individuals if a client makes a credible threat of serious harm. This is a legal and ethical responsibility to protect others from danger, making this the correct statement.
Correct Answer is B
Explanation
Choice A reason: Systematic desensitization is a behavioral therapy technique used to reduce phobias or anxiety by gradually exposing the client to the feared stimulus while teaching relaxation strategies. It does not involve acting out scenarios or practicing new behaviors in a group setting.
Choice B reason: Role playing is the correct answer because it involves acting out scenarios and practicing new behaviors in a safe environment. This technique allows clients to rehearse adaptive responses, gain confidence, and receive feedback. It is widely used in behavioral therapy and group education to promote skill acquisition and behavioral change.
Choice C reason: Biofeedback involves using monitoring devices to provide clients with information about physiological processes such as heart rate or muscle tension. Clients learn to control these processes voluntarily. While effective for stress reduction, it does not involve acting out scenarios or practicing interpersonal behaviors.
Choice D reason: Cognitive restructuring is a cognitive-behavioral technique focused on identifying and challenging distorted thoughts. It helps clients replace maladaptive thinking patterns with healthier ones. While important in therapy, it does not involve role enactment or practicing behaviors in scenarios.
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