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 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:

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.
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.
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:

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.
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.
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.
Evaluation and Quality Improvement: Accurate documentation enables evaluation of the effectiveness of seclusion interventions and contributes to quality improvement initiatives within the healthcare setting.

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Correct Answer is B

Explanation

The correct answer is choice B. Using an electronic messaging system to remind clients when to take medications. Tertiary prevention in healthcare involves measures taken to reduce the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries in order to improve as much as possible their ability to function, their quality of life, and their life expectancy. In the context of an HIV clinic, reminding clients to take their medications can help manage the disease effectively and prevent complications.

Choice A rationale:

Educating clients about contraindications to specific immunizations is incorrect because this is more aligned with primary prevention, which aims to prevent the onset of an illness or injury before the disease process begins.

Choice C rationale:

Providing clients with information about the benefits of exercise is incorrect as this is generally considered a part of primary prevention, promoting general health to prevent various diseases.

Choice D rationale:

Helping clients understand health screenings covered by their insurance plans is incorrect because this is typically associated with secondary prevention, which involves screening to identify diseases in the earliest stages.

A. "I will eat fish for dinner at least twice per week.". B. "I will limit my morning coffee to no more than two cups.". C. "I will eat small, frequent meals.". D. "I should expect my bowel movements to be pale in color". E. "I will notify my provider if my urine is dark.".

Correct Answer is ["C","D","E"]

Explanation

The correct answer is choice CDE.

Choice A rationale:

Eating fish for dinner at least twice per week is not specifically recommended for pancreatitis patients. A low-fat diet is generally advised, but the frequency of fish consumption is not a key point in discharge teaching.

Choice B rationale:

Limiting coffee intake is not a primary focus in pancreatitis discharge instructions. While caffeine can irritate the digestive system, the emphasis is more on avoiding alcohol and fatty foods.

Choice C rationale:

Eating small, frequent meals is recommended to avoid overloading the digestive system and to help manage symptoms of pancreatitis.

Choice D rationale:

Pale bowel movements can indicate a problem with bile flow, which is not a normal expectation for pancreatitis patients. This could suggest a complication that needs medical attention.

Choice E rationale:

Dark urine can be a sign of dehydration or liver issues, which should be reported to a healthcare provider as it may indicate a complication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?

Correct Answer is B

Explanation

A nurse in an emergency department is caring for a client. Exhibits The nurse is preparing to discharge the client. Which of the following statements by the client indicate an understanding of the discharge teaching? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

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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?