A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?
Document the client's behavior every 15 min.
Obtain the provider's prescription within 60 min.
Offer the client food and fluids every 2 hr.
Monitor the client's vital signs every 4 hr.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
No explanation
Correct Answer is C
Explanation
Nurses have an ethical and legal responsibility to maintain the privacy and confidentiality of a client’s personal and health information obtained in the context of the therapeutic nurse-client relationship.There is both federal and provincial legislation to protect a client’s personal and health information, such as the Health Insurance Portability and Accountability Act (HIPAA) and the HIPAA Privacy Rule in the United States.Nurses should only disclose a client’s information to those who have a need to know, such as other health care providers involved in the client’s care, or with the client’s consent.
Based on this information, the appropriate nursing action when the client’s employer calls to discuss the client’s condition is toconsult the client. The nurse should ask the client if they want to share any information with their employer, and respect their wishes.The nurse should not contact the provider, the facility legal department, or the client’s family without the client’s permission, unless there is a legal obligation or a substantial risk of harm to the client or others
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