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
A) Decreased display of emotions:
While changes in emotional expression can occur in individuals with dementia, it's not a primary manifestation that is typically emphasized when educating families. Behavioral and psychological symptoms, including changes in emotion and personality, can be seen in dementia, but forgetfulness progressing to disorientation is a more direct and characteristic symptom of the condition.
B) Forgetfulness gradually progressing to disorientation
Explanation:
When educating the family of a client with dementia, the nurse should inform them to expect forgetfulness that gradually progresses to disorientation. Dementia is a progressive cognitive decline that affects memory, thinking, and reasoning. Forgetfulness is often one of the initial symptoms of dementia, and as the condition advances, individuals can become disoriented to time, place, and even people. This progression occurs due to the degeneration of brain cells and the accumulation of abnormal proteins.
C) Personality traits that are opposite of original traits:
Changes in personality traits can indeed occur as a result of dementia, but this may not be the most prominent or early manifestation that the nurse would want to highlight when educating the family. The gradual progression of forgetfulness leading to disorientation is a more specific and foundational aspect of dementia.
D) Decreased auditory and visual acuity:
Decreased sensory acuity, such as auditory and visual acuity, can happen with age and various health conditions, but they are not primary manifestations of dementia. Dementia primarily affects cognitive functions like memory, thinking, and reasoning.

Correct Answer is C
Explanation
A. "This medication may increase your blood pressure."
This statement is incorrect. Risperidone is not typically associated with significant increases in blood pressure. One of the potential side effects of risperidone is orthostatic hypotension, which is a drop in blood pressure when changing positions (e.g., standing up quickly). Therefore, this choice is not the best instruction to include in the teaching.
B. "Flu-like symptoms are an expected adverse effect of this medication."
This statement is incorrect. While risperidone can have side effects, flu-like symptoms are not commonly associated with it. Common side effects of risperidone may include dizziness, drowsiness, weight gain, and movement disorders. Flu-like symptoms are not a typical adverse effect of this medication.
C. "Avoid becoming overheated while taking this medication."
This statement is correct. Risperidone, like many other antipsychotic medications, can interfere with the body's ability to regulate temperature. This can lead to an increased risk of overheating, especially in hot weather or during vigorous physical activity. Therefore, it's important for patients taking risperidone to be cautious and avoid becoming overheated, as this could potentially lead to heat-related complications.
D. "Muscle twitches can occur the first few weeks while taking this medication."
This statement is incorrect. Muscle twitches are not a common side effect of risperidone. While it's true that some movement disorders can occur with antipsychotic medications, the statement is too specific to muscle twitches and does not accurately reflect the typical side effect profile of risperidone.
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