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 ["24"]
Explanation
To calculate the mL/hr for the heparin infusion, you can use the formula:
mL/hr = (Total units required per hour) / (Units/mL in the solution)
Given:
Total units required per hour = 1,200 U/hr
Units/mL in the solution = 25,000 U / 500 mL = 50 U/mL
Plugging in the values:
mL/hr = (1,200 U/hr) / (50 U/mL)
mL/hr = 24 mL/hr (rounded to the nearest tenth)
Therefore, the nurse should set the IV pump to deliver 24 mL/hr for the heparin infusion.
Correct Answer is C
Explanation
A. The client is unwilling to accept that treatment is needed.
This alone may not be sufficient to keep the client under a 72-hour hold. While a person's refusal to accept treatment may indicate a need for care, it might not meet the criteria for involuntary commitment unless there is an immediate danger to the individual or others.
B. The client states that she does not like the neighbor.
Disliking a neighbor is not typically a sufficient reason to place someone under a 72-hour psychiatric hold. The criteria for involuntary commitment usually revolve around a person's potential to harm themselves or others due to their mental state.
C. The client is a danger to herself or others.
Explanation:
In many jurisdictions, a 72-hour psychiatric hold, also known as an involuntary psychiatric hold or emergency detention, allows mental health professionals to detain a person who is considered a danger to themselves or others due to their mental condition. This is done to ensure the safety of the individual and those around them. The hold provides a brief period during which a psychiatric assessment can be conducted to determine the appropriate course of action for the person's mental health treatment.
D. The client states that she plans to move out of the state immediately.
While this statement might raise concerns about the client's stability, it generally would not meet the criteria for a 72-hour hold unless there is clear evidence that the client's immediate move would pose a risk to their own safety or the safety of others. The hold is more focused on imminent danger rather than potential future actions.
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