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 A
Explanation
A. This question assesses the client's perception of the impact of the stroke on their life, providing insight into their coping abilities and emotional response.
B. This question addresses acceptance but may not fully assess the client's coping strategies or emotional response to the stroke.
C. This question addresses practical assistance with hygiene tasks but does not directly assess coping mechanisms.
D. This question focuses on the cause of the stroke rather than the client's coping abilities or emotional response.
Correct Answer is A
Explanation
A. Encouraging physical activity during the day has been shown to improve mood and reduce symptoms of depression by increasing endorphin levels and promoting a sense of well-being.
B. Identifying and scheduling alternative group activities for the client may be helpful in reducing social isolation and improving mood but should not replace physical activity.
C. Discouraging the client from expressing feelings of anger is not appropriate, as it may suppress emotions and hinder therapeutic communication. Instead, the nurse should encourage the client to express and explore their emotions in a healthy manner.
D. Keeping a bright light on in the client's room at night may disrupt sleep patterns and exacerbate symptoms of depression, as individuals with depression often have disturbances in their sleep-wake cycle.
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