A nurse is receiving a change-of-shift report about a group of assigned clients at a mental health facility. Which of the following clients should the nurse assess for risks related to sensory impairments?

The correct answer is B. Obtain a prescription for seclusion within 30 minutes. This ensures the seclusion is legally and ethically justified.

Choice A reason:

Keeping the client in seclusion for no longer than 6 hours is incorrect because the maximum duration for seclusion without reassessment is typically 4 hours for adults.

Choice B reason:

Obtaining a prescription for seclusion within 30 minutes is correct as it ensures the seclusion is legally and ethically justified.

Choice C reason:

Monitoring the client's vital signs every 4 hours is incorrect because vital signs should be monitored more frequently, usually every 15 minutes to 1 hour.

Choice D reason:

Documenting the client's behavior every 60 minutes is incorrect because documentation should occur more frequently, typically every 15 minutes.

Choice A reason: Providing a client with a timeline for grieving is not recommended as grief is a highly individual experience and does not follow a set timeline. Each person's journey through grief is unique, and imposing a timeline may invalidate their feelings and hinder the natural process of grieving.

Choice B reason: Encouraging the client to express their feelings is considered a best practice in nursing care for patients with dementia experiencing anticipatory grief. It allows the patient to acknowledge and work through their emotions, which is an important aspect of coping with grief. Open communication can also help the nurse to assess the patient's emotional state and provide appropriate support.

Choice C reason: While showing sympathy can be comforting, it is more beneficial to show empathy. Empathy involves understanding and sharing the feelings of another, which helps in building a stronger connection and providing more personalized care. Sympathy might sometimes be perceived as pity, which can be counterproductive in the therapeutic relationship.

Choice D reason: Sharing personal stories of grief with the client is generally not advised as the focus should remain on the client's experiences. The nurse's role is to facilitate the client's expression of grief, not to shift the focus to their own experiences. Personal stories may also trigger additional stress for the client.