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","B","D","E"]
Explanation
A. Hyperactivity: While some individuals with eating disorders may engage in excessive physical activity as a form of compensatory behavior, hyperactivity is not a consistent and universal manifestation.
B. Amenorrhea: Adolescents with eating disorders, particularly anorexia nervosa, often experience amenorrhea (absence of menstrual periods) due to hormonal imbalances and low body weight.
C. Verbalized desire to gain weight: Individuals with eating disorders, especially anorexia nervosa, often express a strong desire to lose weight rather than gain weight, which contributes to their restrictive eating habits.
D. Altered body image: Eating disorders are often associated with distorted body image, where individuals perceive themselves as overweight or larger than they actually are, even if they are underweight.
E. Bradycardia: Severe malnutrition, as seen in eating disorders like anorexia nervosa, can lead to bradycardia (slow heart rate) as the body conserves energy in response to the low caloric intake.
Correct Answer is C
Explanation
A. Brief Patient Health Questionnaire (Brief PHQ):
The Brief PHQ is a screening tool used to assess symptoms of depression. While it may be relevant to assess mood and emotional well-being, it is not specific to evaluating cognitive functioning or cognitive disorders.
B. Abnormal Involuntary Movements Scale (AIMS):
The AIMS is used to assess involuntary movements, particularly in individuals taking antipsychotic medications. It is not directly related to assessing cognitive disorders.
C,. Mental status examination (MSE)
Explanation:
When admitting an older adult client with a suspected cognitive disorder, including a mental status examination (MSE) as part of the assessment is crucial. The MSE is a structured assessment of a client's current cognitive functioning, emotional state, and thought processes. It helps to evaluate memory, attention, language, perception, orientation, mood, and other cognitive and emotional domains.
D. Scale for Assessment of Negative Symptoms (SANS):
The SANS is used to assess negative symptoms in individuals with schizophrenia. It focuses on features such as affective blunting, alogia, anhedonia, and other negative symptoms. While it may provide important information about a client's mental state, it is not primarily used to assess cognitive disorders.
Assessing cognitive function is a key component when evaluating older adult clients for cognitive disorders such as dementia or other cognitive impairments. The MSE provides valuable information to guide diagnosis and treatment planning for these conditions.
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