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

Obtain the provider's prescription within 60 min.

Document the client's behavior every 15 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 B

Choice A reason:

Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.

Choice B reason:

Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.

Choice C reason:

Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.

Choice D reason:

Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.

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Correct Answer is C

Explanation

Physical activity can help improve mood, energy, sleep, and cognitive function in clients who have major depressive disorder. It can also reduce stress and increase self esteem.

A. Refusing to participate in group activities B. Talking negatively about other staff members C. Expressing frustration regarding unit rules D. Reacting to the nurse as though she were his mother

Correct Answer is D

Explanation

Transference is a defense mechanism in which the client unconsciously transfers feelings, attitudes, or impulses from a past relationship to a current one, such as a health care provider. The nurse should recognize this behavior and maintain professional boundaries with the client. The other options are not specific to transference and may indicate other issues.

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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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