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 B
Explanation
While the behavior may occupy the client's time and attention, the primary motivation behind OCD-related compulsions is not to engage in meaningful tasks but rather to alleviate anxiety caused by obsessive thoughts.
B. Decrease anxiety to a tolerable level.
Explanation: Individuals with obsessive-compulsive disorder (OCD) often engage in compulsive behaviors, such as cleaning, organizing, or checking, as a way to reduce the anxiety caused by their obsessive thoughts. In this scenario, the client's constant picking up after others is likely a compulsive behavior that serves the purpose of decreasing their anxiety to a tolerable level. The act of tidying up may temporarily alleviate the distress caused by obsessive thoughts related to cleanliness, order, or potential harm.
C. Manipulate and control others' behaviors.
The behavior described does not inherently indicate a desire to manipulate or control others. The behavior is driven by the client's internal anxiety rather than an intention to control external factors.
D. Limit the amount of time available to interact with others.
The behavior is more closely related to managing anxiety than limiting social interactions. OCD-related behaviors are driven by the need to reduce distress, not necessarily to avoid interacting with others.
Correct Answer is D
Explanation
A. Discuss self-defense techniques with the client: Incorrect
While self-defense techniques can be useful information, discussing them immediately after a traumatic event like sexual assault may not be appropriate. The client's immediate needs for emotional support, medical evaluation, and safety are more pressing.
B. Give the client a bed bath prior to physical examination: Incorrect
In cases of sexual assault, preserving evidence is important for legal purposes and for the client's well-being. Providing a bed bath could potentially compromise evidence and hinder a thorough examination by healthcare professionals.
C. Inform the client photographs of injuries are required for a police report: Correct
Preserving evidence is crucial in cases of sexual assault, especially if the client intends to involve law enforcement. Informing the client about the importance of photographs for a police report is appropriate and can contribute to a potential legal investigation.
D. Ask the client to describe the situation: Correct
It's important to encourage the client to share their experience, but it should be done in a sensitive and supportive manner. Gathering information about the situation can help the healthcare team understand the scope of the assault, provide appropriate medical care, and offer necessary emotional support.
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