A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?

Choice A rationale:

Documenting the client's behavior every 15 minutes is a valid nursing action when a client is placed in seclusion. However, it is not the most critical step to take in this situation. The safety and well-being of the client and staff are paramount, and obtaining the provider's prescription is more crucial.

Choice B rationale:

The correct choice. Obtaining the provider's prescription within 60 minutes is essential when a client is placed in seclusion. Seclusion is an intervention that restricts the client's freedom, and it should only be done under the supervision of a licensed healthcare provider. The nurse must obtain a prescription for this intervention as soon as possible to ensure that the client's rights and safety are respected.

Choice C rationale:

Offering the client food and fluids every 2 hours is a valid nursing action in a seclusion situation. However, it is not the most immediate priority. Obtaining the provider's prescription takes precedence to ensure the appropriateness of the intervention.

Choice D rationale:

Monitoring the client's vital signs every 4 hours is an important nursing action, but it is not the primary step to take immediately after placing a client in seclusion. Obtaining the provider's prescription is more urgent to ensure the legality and appropriateness of the intervention.

The correct answer is Choice d. "Tell me the reasons you think your mother is depressed."

Rationale for Choice a. "Everyone gets depressed from time to time."

• This response is dismissive and minimizes the daughter's concerns. It suggests that depression is not a serious condition and does not warrant professional attention.
• It fails to acknowledge the daughter's feelings of worry and anxiety.
• It does not gather any information about the mother's symptoms or the reasons for the daughter's concern.

Rationale for Choice b. "Older adults are usually diagnosed with depressive disorder as they age."

• While it is true that depression is more common in older adults, this response does not address the daughter's concerns about her mother's specific symptoms.
• It may unnecessarily alarm the daughter by suggesting that depression is an inevitable part of aging.
• It does not encourage the daughter to share her observations and concerns.

Rationale for Choice c. "You shouldn't worry about this, because depressive disorder is easily treated."

• This response is premature and potentially misleading. It offers reassurance without first gathering enough information to determine whether the mother is actually depressed.
• It may discourage the daughter from sharing important details about her mother's condition.
• It implies that treatment for depression is always simple and straightforward, which is not always the case.

Rationale for Choice d. "Tell me the reasons you think your mother is depressed."

• This response is the most appropriate because it encourages the daughter to share her observations and concerns.
• It demonstrates that the nurse is taking the daughter's concerns seriously.
• It allows the nurse to gather more information about the mother's symptoms and the potential reasons for her depression.
• It opens the door to further assessment and discussion, which are essential for accurate diagnosis and treatment planning.