A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?
A school-age client who attempts to repeatedly bite staff.
An older adult client who is manic and agitated due to overstimulation.
An adolescent client who throws objects at other clients.
An adult client after an interrupted suicide attempt.
The Correct Answer is D
Choice A rationale:
Seclusion may be considered for a school-age client who repeatedly bites staff as a method of last resort to ensure the safety of both the client and staff.
It's important to exhaust other interventions first, such as verbal de-escalation, redirection, and medication.
If seclusion is used, it should be implemented under strict guidelines, with close monitoring and frequent reassessment to determine its effectiveness and necessity.
Choice B rationale:
Seclusion may be considered for an older adult client who is manic and agitated due to overstimulation, as it can provide a safe and quiet environment to reduce sensory input and promote calming.
However, it's crucial to carefully assess the client's physical and cognitive status, as seclusion can exacerbate confusion and disorientation in older adults.
Close monitoring and reassessment are essential.
Choice C rationale:
Seclusion may be considered for an adolescent client who throws objects at other clients to maintain safety and prevent harm to others.
It's important to first attempt other interventions, such as verbal de-escalation, redirection, and limit-setting.
If seclusion is used, it should be brief and implemented with therapeutic goals in mind, such as promoting self-regulation and problem-solving skills.
Choice D rationale:
Seclusion is contraindicated for an adult client after an interrupted suicide attempt.
This is because seclusion can increase isolation, hopelessness, and despair, which are significant risk factors for suicide.
It can also hinder close observation and monitoring of the client's mental state, potentially leading to further suicide attempts.
Instead, the focus should be on providing supportive, one-to-one contact, ensuring safety, and establishing therapeutic rapport to address the underlying issues that led to the suicide attempt.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer/s is C
Choice A rationale: Hyperkalemia, or high potassium levels in the blood, is not typically associated with anorexia nervosa. In fact, individuals with anorexia nervosa are more likely to experience hypokalemia, or low potassium levels, due to inadequate dietary intake and excessive loss of potassium through vomiting or use of diuretics1.
Choice B rationale: Metrorrhagia, or irregular menstrual bleeding between periods, can occur in females with anorexia nervosa due to hormonal imbalances caused by extreme weight loss and malnutrition. However, amenorrhea, or the absence of menstruation, is more commonly observed1.
Choice C rationale: Lanugo, which is fine, soft hair that grows on the face and body, is a common finding in individuals with anorexia nervosa. It is the body’s response to severe weight loss and starvation as an attempt to provide insulation and maintain body temperature1.
Choice D rationale: Tachycardia, or a rapid heart rate, is not typically associated with anorexia nervosa. Instead, individuals with anorexia nervosa often experience bradycardia, or a slower than normal heart rate, as the body’s response to starvation1.
Correct Answer is C
Explanation
Choice A rationale: While a heart rate of 52/min is lower than the normal range (60-100/min), it’s not uncommon in individuals with anorexia nervosa due to the body’s adaptation to conserve energy.
However, it’s not the most critical vital sign to address first in this scenario.
Choice B rationale: A respiratory rate of 26/min is slightly elevated (normal range is 12-20/min), possibly due to anxiety or distress.
However, it’s not the most immediate concern compared to other vital signs.
Choice C rationale: The client’s blood pressure is 84/50 mm Hg, which is significantly lower than the normal range (90/60 to 120/80 mm Hg). This could indicate hypotension, which can lead to dizziness, fainting, and inadequate blood flow to organs.
Hypotension is a common complication of anorexia nervosa due to decreased blood volume and weakened heart muscle.
Therefore, it should be addressed first.
Choice D rationale: The client’s temperature is 36.1°C (97°F), which is slightly lower than the normal body temperature range (36.5–37.5°C or 97.7–99.5°F). Hypothermia is a common complication in individuals with anorexia nervosa due to loss of body fat, which provides insulation.
However, it’s not the most immediate concern in this scenario.
In conclusion, the nurse should first address the client’s blood pressure due to the potential risks associated with hypotension.
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