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. "I think you should calm down a little before you see your partner.":
Explanation: This response might come across as dismissive or insensitive to the partner's feelings. It's important to acknowledge the partner's emotions and offer support rather than suggesting they should calm down.
B. "Do not worry about that. Your wife will be fine.":
Explanation: While it's reassuring to say that the patient will be fine, dismissing the partner's feelings and concerns is not supportive. The partner needs a chance to express their emotions and concerns.
C. "Tell me more about your feelings about what happened to your partner.":
Explanation: Correct Answer. This response is empathetic and encourages the partner to express their emotions. It shows that the nurse is actively listening and is willing to provide a safe space for the partner to share their feelings.
D. "Why do you think the crash is your fault?":
Explanation: This response might come across as accusatory or confrontational, which could exacerbate the partner's feelings of guilt. Instead, the nurse should focus on providing support and understanding.
Correct Answer is B
Explanation
A. Helping the client identify positive personality traits.
While addressing self-esteem and positive personality traits is valuable for the client's overall well-being, it is not the immediate priority during the detoxification phase. Ensuring physiological safety comes first.
B. Providing for adequate hydration and rest.
Explanation: The detoxification process from alcohol can result in withdrawal symptoms that range from mild discomfort to severe medical complications. Adequate hydration and rest are essential during this phase to manage withdrawal symptoms and prevent potential complications such as dehydration, electrolyte imbalances, and seizures. Maintaining the client's physiological stability is of utmost importance.
C. Educating the client about the consequences of alcohol misuse.
Providing education about the consequences of alcohol misuse is important for the client's understanding and motivation for recovery, but it's not the primary concern during the initial detoxification phase.
D. Confronting the use of denial and other defense mechanisms.
Addressing denial and defense mechanisms is important for therapy, but it might not be the immediate priority. Physiological stabilization through hydration and rest takes precedence in the detoxification phase.
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