A nurse is assessing a client who is experiencing hypovolemia.

Which of the following manifestations should the nurse expect

The correct answer is c. Document the client's behavior prior to being placed in seclusion.

Rationale for Choice a. Discuss with the client his inappropriate behavior prior to seclusion:

While discussing the client's behavior may be helpful in some situations, it is not the most appropriate action to take immediately before seclusion. This is because:

1. Escalation:Attempting to discuss behavior in the moments leading up to seclusion can potentially escalate the situation and further jeopardize the safety of the client,staff,and other patients.
2. Impaired Insight:Clients requiring seclusion may have limited ability to engage in rational discussion due to heightened emotional states,cognitive impairment,or acute mental illness.
3. Limited Receptiveness:The client may not be receptive to feedback or discussion while in a state of crisis,potentially leading to frustration and further agitation.

Rationale for Choice b. Offer fluids every 2 hr.:

Offering fluids is a basic nursing intervention, but it is not the priority action in this scenario. The primary focus at this time is ensuring safety and managing the acute behavioral crisis. Addressing hydration needs can be attended to after the client is safely placed in seclusion.

Rationale for Choice d. Assess the client’s behavior once every hour.:

Regular assessment is crucial, but hourly assessment is not frequent enough in this situation. Clients in seclusion require close monitoring and assessment at more frequent intervals to ensure their safety and well-being, as well as to evaluate the effectiveness of the seclusion intervention.

Rationale for Choice c. Document the client’s behavior prior to being placed in seclusion.:

This is the most appropriate action for the nurse to take for the following reasons:

1. Legal and Ethical Requirements:Accurate documentation of the client's behavior prior to seclusion is essential for legal and ethical reasons.It serves as a record of the rationale for seclusion,supporting the decision-making process and ensuring adherence to best practices and patient rights.
2. Assessment and Intervention Planning:Detailed documentation provides valuable information for ongoing assessment and intervention planning.It allows healthcare professionals to track the client's progress,identify patterns in behavior,and make informed decisions about the continuation or discontinuation of seclusion.
3. Communication and Collaboration:Comprehensive documentation facilitates effective communication and collaboration among the healthcare team members,ensuring continuity of care and promoting a holistic approach to the client's treatment.
4. Evaluation and Quality Improvement:Accurate documentation enables evaluation of the effectiveness of seclusion interventions and contributes to quality improvement initiatives within the healthcare setting.

This prescription is complete because it includes the medication name, dose, route, and frequency.

A complete prescription should also include the client’s name, date, time, signature of the prescriber, and any special instructions.

Choice A is wrong because it does not specify the dose of cimetidine.

PO twice daily is not enough information to administer the medication safely.

Choice B is wrong because it does not specify the frequency of tetracycline.

200 mg PO is not enough information to administer the medication safely.

Choice C is wrong because it does not specify the route of epoetin alfa.

150 units/kg three times weekly is not enough information to administer the medication safely.

Normal ranges for digoxin are 0.5 to 2 ng/mL for heart failure and 0.8 to 2 ng/mL for atrial fibrillation.

Normal ranges for cimetidine are 50 to 150 ng/mL.

Normal ranges for tetracycline are 1 to 10 mcg/mL.

Normal ranges for epoetin alfa are not applicable as it is a synthetic hormone that stimulates red blood cell production.