A nurse in an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?
An adolescent client who throws objects at other clients
An older adult client who is manic and crying due to overstimulation
A school-age client who attempts to repeatedly bite staff
An adult client following a suicide attempt
The Correct Answer is D
A. An adolescent client who throws objects at other clients:
Explanation: Seclusion is contraindicated for this client due to safety concerns. The behavior of throwing objects at others indicates a potential danger to both the client and others in a confined space. Placing the client in seclusion could escalate the situation and potentially lead to further harm.
B. An older adult client who is manic and crying due to overstimulation:
Explanation: Seclusion might be contraindicated for this client as well. Older adults experiencing manic behavior and emotional distress could be further traumatized by seclusion. Alternatives like providing a calm and soothing environment, along with appropriate medications, might be more beneficial for this client.
C. A school-age client who attempts to repeatedly bite staff:
Explanation: Seclusion is a potential option for this client. The repeated attempts to bite staff pose a risk of physical harm to both the client and staff members. Seclusion might be used as a last resort to ensure the safety of everyone involved.
D. An adult client following a suicide attempt:
Explanation: Seclusion is generally contraindicated for clients who have attempted suicide. Placing them in isolation can worsen feelings of despair and isolation, potentially increasing the risk of self-harm or suicide. These clients require close monitoring, support, and therapeutic interventions to address the underlying issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Identify the client's nutritional status.
Explanation:
Given the significant weight loss and the client's distorted belief about her body image (believing she is fat despite losing weight), it is crucial to assess the client's nutritional status first. Rapid weight loss and distorted body image are characteristic features of an eating disorder, such as anorexia nervosa. The nurse needs to determine the extent of malnutrition and potential medical complications related to inadequate nutrition. This assessment will guide the subsequent interventions.
Why the other choices are incorrect:
B. Provide a structured environment for the client.
While providing a structured environment can be important in managing eating disorders, such as anorexia nervosa, it is not the first priority. Understanding the client's nutritional status and medical condition takes precedence.
C. Plan a therapeutic diet for the client.
Planning a therapeutic diet may be part of the client's care plan, but without understanding the underlying nutritional status and potential eating disorder, creating a diet plan may not be effective or appropriate.
D. Request a mental health consult.
While a mental health consult is important for addressing the client's distorted body image and potential eating disorder, it should follow the assessment of nutritional status. The nutritional assessment provides critical information for both medical and psychological interventions.
Correct Answer is B
Explanation
Fluoxetine and other SSRIs can actually have an impact on sexual desire and function as a side effect, often leading to decreased libido. This statement shows a misunderstanding of the medication's potential effects.
B. "I should notify my provider if I develop a skin rash."
Explanation: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression. It's important for clients to be aware of potential side effects and know when to notify their healthcare provider. One potential serious side effect is an allergic reaction or skin rash, which could indicate an adverse response to the medication. Therefore, the client's statement about notifying the provider if a skin rash develops demonstrates their understanding of monitoring for potential adverse reactions.
C. "I should expect relief from depression within 3 to 4 days."
Antidepressant medications like fluoxetine typically take several weeks to start showing significant improvements in symptoms. This statement reflects a misconception about the timeline for therapeutic effects.
D. "I will take my fluoxetine at bedtime so I can sleep better."
Fluoxetine can have stimulating effects for some individuals, so it's often recommended to take it earlier in the day to avoid interference with sleep. Taking it at bedtime could potentially disrupt sleep rather than improve it.
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