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.
Monitor the client's vital signs every 4 hr.
Offer the client food and fluids every 2 hr.
The Correct Answer is A
A. Documenting the client's behavior every 15 minutes is essential for monitoring the client's condition, response to seclusion, and any changes in behavior or status.
B. Obtaining the provider's prescription within 60 minutes may be necessary but does not address immediate nursing actions required after placing the client in seclusion.
C. Monitoring vital signs every 4 hours is not specific to managing a client in seclusion and may not provide timely information about the client's condition or response to seclusion.
D. Offering food and fluids every 2 hours is important for meeting the client's physiological needs but may not be appropriate immediately after placing the client in seclusion, depending on the circumstances and facility policies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- Choice A Rationale: This statement does not indicate spiritual distress. On the contrary, it suggests that the client's faith is a source of strength and hope, which is typically a sign of positive spiritual well-being.
- Choice B Rationale:
This statement suggests a disruption in the client's spiritual practices, which could lead to spiritual distress as it interferes with a meaningful coping mechanism.
- Choice C Rationale: Similar to choice A, this statement reflects a positive aspect of the client's spirituality. Finding comfort in meditation is indicative of a beneficial spiritual practice and does not suggest distress.
- Choice D Rationale:
This reflects active spiritual support, which is helpful during illness and not indicative of spiritual distress.
Correct Answer is C
Explanation
A. Meeting one's own needs without manipulating others may be a desirable outcome but is not specific to the core deficits of autism spectrum disorder.
B. Acknowledging that delusions are not real is more relevant to psychotic disorders rather than autism spectrum disorder.
C. Initiating social interactions with caregivers is an appropriate outcome for individuals with autism spectrum disorder, as it reflects improved social communication skills and social engagement.
D. Individuals with autism spectrum disorder may have difficulty understanding and responding to peer pressure, so changing behavior as a result of peer pressure may not be a realistic or desirable outcome.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.