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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Informing the client about confidentiality rights typically occurs during the orientation phase of the therapeutic relationship, not the working phase.
B. Establishing boundaries between the nurse and the client is an ongoing process that occurs throughout the therapeutic relationship, not just during the working phase.
C. Setting short- and long-term objectives for the future typically occurs during the orientation phase and continues throughout the therapeutic relationship, not just during the working phase.
D. During the working phase of the therapeutic relationship, the nurse and client collaborate to achieve the goals identified during the orientation phase. The nurse evaluates the client's progress toward these goals and adjusts interventions as necessary to promote therapeutic outcomes.
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