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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Methadone hydrochloride is not indicated for the management of alcohol intoxication or withdrawal. It is primarily used for opioid addiction treatment.
B. While monitoring for orthostatic hypotension is important in clients with alcohol use disorder, implementing seizure precautions is a higher priority because alcohol withdrawal can lead to
seizures.
C. Acidifying the client's urine is not indicated in the care of an intoxicated client with alcohol use disorder.
D. Implementing seizure precautions is essential in clients with alcohol use disorder who are at risk for alcohol withdrawal syndrome, which can include seizures as a potential complication.

A. "Have you been thinking about harming yourself?" B. "Why do you feel like things will never work out?" C. “You should try to focus on yourself for a change." D. “Maybe an antidepressant will make you feel better."

Correct Answer is A

Explanation

A. This response directly addresses the potential for self-harm, which is a critical concern when a client expresses hopelessness. It is an open-ended question that invites the client to discuss their feelings and provides the nurse with information to assess the client's safety.
B. Asking the client a why question may not be alright and this may make them to be guarded.
C. This response may come off as dismissive and lacks empathy towards the client's feelings.
D. Suggesting medication without further assessment is premature and may not address the root cause of the client's statement.

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A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

Explanation

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