A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?

Discuss with the client his inappropriate behavior prior to seclusion.

Offer fluids every 2 hr.

Document the client’s behavior prior to being placed in seclusion.

Assess the client’s behavior once every hour.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C: Document the client’s behavior prior to being placed in seclusion.

Choice A rationale:

Discussing with the client his inappropriate behavior prior to seclusion is important, but it’s not the most appropriate action. The priority is to ensure the safety of the client and others, which can be achieved by documenting the client’s behavior prior to seclusion.

Choice B rationale:

Offering fluids every 2 hours is a good practice to keep the client hydrated, especially if they are agitated or physically active. However, this is not the most appropriate action in this context.

Choice C rationale:

Documenting the client’s behavior prior to being placed in seclusion is the most appropriate action. This documentation is crucial for legal and ethical reasons, and it helps in evaluating the effectiveness of the intervention.

Choice D rationale:

Assessing the client’s behavior once every hour is important to monitor the client’s condition and response to seclusion. However, this is not the most appropriate action in this context.

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Correct Answer is A

Explanation

This is because boundaries can help the client and family to respect each other’s roles, needs, and preferences, and to avoid role confusion, resentment, or guilt. Boundaries can also promote independence and self-care for the client, as well as prevent caregiver burnout for the family.
Choice B is wrong because minimizing open discussion regarding the changes can lead to misunderstanding, frustration, or isolation. The client and family should communicate openly and honestly about their feelings, expectations, and challenges, and seek support when needed.
Choice C is wrong because authoritative communication from the adult child can create a power imbalance, undermine the client’s autonomy and dignity, or cause conflict or resistance. The client and family should use respectful and collaborative communication, and involve the client in decision-making as much as possible.
Choice D is wrong because decreasing socialization with extended relatives can reduce the client and family’s support network, increase their stress or loneliness, or limit their opportunities for meaningful activities. The client and family should maintain contact with their relatives and friends, and participate in social or recreational activities that they enjoy.

A. Nonreactive pupils. B. Serpentine limb movement. C. Smacking lips. D. Shuffling gait.

Correct Answer is D

Explanation

This is because shuffling gait is a common manifestation of pseudo-parkinsonism, which is a condition that mimics the symptoms of Parkinson’s disease due to the use of certain medications that block dopamine receptors, such as haloperidol. Pseudoparkinsonism can cause slowed movements, muscle stiffness, tremor, and postural instability.
Choice A. Nonreactive pupils are wrong because this is not a typical feature of pseudoparkinsonism or Parkinson’s disease.
Nonreactive pupils can be caused by other conditions, such as brain injury, drugs, or eye diseases.
Choice B. Serpentine limb movement is wrong because this is a characteristic of tardive dyskinesia, another drug-induced movement disorder that can result from the long-term use of dopamine receptor-blocking agents. Tardive dyskinesia causes involuntary movements of the face, tongue, and limbs that are often writhing or twisting.
Choice C. Smacking lips is wrong because this is also a sign of tardive dyskinesia, not pseudo-parkinsonism. Smacking lips is one of the orofacial movements that can occur in tardive dyskinesia due to abnormal muscle contractions.

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A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?

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