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 C
Explanation
A. The client has begun playing basketball with several other clients during the past month.
Engaging in activities and social interactions can actually be a positive sign, as it suggests involvement and connection with others, which can be protective against suicide.
B. The client identifies with problems expressed by other clients.
Identifying with others' problems may indicate empathy, but it is not necessarily indicative of suicide risk on its own.
C. The client's behavior has become impulsive in the past few weeks.
Explanation: Impulsivity can be a significant risk factor for suicide. A sudden increase in impulsive behavior might indicate that the client is not thinking clearly and is acting without considering the potential consequences. Impulsivity can lead to actions that are harmful or dangerous, including suicidal behaviors.
D. The client states she wants to go home to be with her children and partner.
Expressing a desire to be with loved ones is generally not an indicator of suicide risk. In fact, having a strong support system can be protective against suicidal thoughts.
Correct Answer is C
Explanation
A. "You are being unreasonable, and I will not call your doctor at this hour."
This response is confrontational and dismissive of the client's request. It does not promote a therapeutic interaction and might escalate the situation.
B. "Go back to your room, and I'll try to get in touch with your doctor."
This response might temporarily calm the client, but it’s misleading if the nurse does not intend to call the doctor. It also avoids addressing the client's immediate emotional needs and could result in a loss of trust if the nurse doesn’t follow through.
C. "You must be very upset about something."
This is the most therapeutic response. It acknowledges the client’s feelings without judgment and opens up communication. It allows the nurse to explore the client’s concerns, which is essential in providing appropriate care and support in a psychiatric setting.
D. "I can't call a doctor in the middle of the night unless it's an emergency."
While this statement is factually correct, it can come across as dismissive and could escalate the client's agitation. It does not acknowledge the client's emotions and might make the client feel that their concerns are not being taken seriously.
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