A patient with psychosis became aggressive, struck another patient, and required seclusion. Select the best documentation.
Patient struck another patient who attempted to leave day room to go to bathroom. Seclusion necessary at 1415. Plan: Maintain seclusion for 8 hours and keep these two patients away from each other for 24 hours.
Patient aggressive today, was medicated as per doctors orders and placed in seclusion.
Seclusion ordered by physician for aggressive behaviour. Begun at 1415. Maintained for 2 hours without incident. Outcome: Patient calmer and apologized for outburst.
Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 patient yelled, "I'll punch anyone who gets near me,” and struck another patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained from physician at 1430.
The correct answer is: d) Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 patient yelled, "I'll punch anyone who gets near me,” and struck another patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained from physician at 1430.
The Correct Answer is D
Choice A reason: This documentation is insufficient because it lacks the specific behavioral "trail" leading up to the incident. Furthermore, "maintaining seclusion for 8 hours" as a pre-planned goal is inappropriate, as patients must be released as soon as they meet safety criteria, regardless of an arbitrary time frame set by staff.
Choice B reason: This entry is too vague and uses subjective labeling ("aggressive"). High-quality psychiatric documentation must describe specific, observable actions and the failure of less restrictive measures (like the medication mentioned) rather than using generalized adjectives that do not provide a clear picture of the clinical necessity for seclusion.
Choice C reason: While this provides a start time and an outcome, it fails to document the specific events that occurred prior to the seclusion. It does not show that the nurse attempted less restrictive interventions first, which is a vital legal and ethical requirement when documenting the use of restrictive measures in a psychiatric setting.
Choice D reason: This is the best documentation because it follows a chronological, objective sequence. It includes the patient's early behavior (pacing, shouting), the attempt at a less restrictive intervention (oral medication), the specific threat, the actual act of violence, and the precise times for the intervention and the physician's order.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Vegetative signs typically refer to the slowing of bodily functions, such as increased sleep and constipation, often seen in depression. While "not eating" can occur in mania, the overall description of rhymes and intense online activity suggests high energy rather than the lethargy associated with poor grooming.
Choice B reason: Increased muscle tension and anxiety are primary symptoms of Generalized Anxiety Disorder or panic states. While a manic patient may feel "wired," their behavior is characterized more by expansive energy, grandiosity, and goal-directed activity than by the fearful apprehension seen in clinical anxiety.
Choice C reason: While manic patients may eventually become paranoid if psychosis develops, the specific behaviors described—excessive posting and lack of sleep—are hallmark signs of behavioral dysregulation and psychomotor agitation. Cognitive deficits in mania are usually related to distractibility rather than a permanent loss of cognitive function.
Choice D reason: Remaining online for 24 hours and contacting public officials inappropriately demonstrates poor judgment and a lack of impulse control. The inability to stop for sleep or food for 3 days is a clear indicator of psychomotor hyperactivity, which is a core diagnostic feature of a manic episode.
Correct Answer is C
Explanation
Choice A reason: While some studies have suggested a statistical link between creativity and bipolar disorder, this observation does not provide scientific evidence for "genetic transmission." It reflects a possible correlation in phenotype or behavior rather than demonstrating a clear hereditary or genotypic pattern of inheritance for the disorder.
Choice B reason: Exaggerated responses to stress (emotional reactivity) may be a temperamental trait, but it is not specific evidence for the genetic transmission of bipolar disorder. Genetic evidence must specifically link the occurrence of the clinical diagnosis itself across generations within a family tree to be considered valid evidence.
Choice C reason: This statement accurately reflects findings from family, twin, and adoption studies. The risk for bipolar disorder is significantly higher among first-degree relatives of affected individuals compared to the general population. This familial aggregation is the primary clinical evidence supporting a strong hereditary and genetic component for the disorder.
Choice D reason: Socioeconomic and educational backgrounds are environmental and social factors. While early research once suggested a link between higher socioeconomic status and bipolar disorder, these findings have largely been debunked and do not contribute to the scientific understanding of the biological and genetic roots of the illness.
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