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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Clozapine is an antipsychotic medication that can cause agranulocytosis, a potentially life-threatening condition that reduces the number of white blood cells and increases the risk of infection. A sore throat is a sign of infection and should be reported immediately. The other clients are not in immediate danger and can be seen later.
Correct Answer is D
Explanation
The correct answer is: D. The client has several siblings.
Choice A reason:
The client being the oldest of their siblings is not directly linked to the development of conduct disorder. Conduct disorder is more influenced by factors such as family conflict, inconsistent discipline, and parental issues rather than birth order.
Choice B reason:
The client's father living in the client's home does not inherently contribute to conduct disorder. The presence of a father figure can be a stabilizing factor unless there are issues such as abuse, neglect, or inconsistent parenting.
Choice C reason:
The client's mother having asthma is unrelated to the development of conduct disorder. Conduct disorder is typically associated with psychological, social, and familial factors rather than the physical health conditions of parents.
Choice D reason:
The client having several siblings can contribute to conduct disorder due to potential for increased familial conflict and competition for parental attention. Larger family sizes can sometimes lead to less individual attention and more sibling rivalry, which can exacerbate behavioral issues.
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