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.
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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Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
The nurse should first administer oxygen at 2 L/min via nasal cannula because the client has signs of hypoxemia (low oxygen saturation) and respiratory distress (increased respiratory rate) that may worsen the chest pain and myocardial ischemia. Oxygen therapy can help improve oxygen delivery to the heart muscle and reduce the workload of the heart.
The nurse should then administer sublingual nitroglycerin as prescribed because nitroglycerin is a vasodilator that can help relieve chest pain by dilating the coronary arteries and improving blood flow to the heart. Nitroglycerin can also lower blood pressure and reduce cardiac preload and afterload, which can decrease myocardial oxygen demand.
Other choices:
• Prepare the client for cardiac catheterization: This may be a later intervention if the chest pain persists or if the client has a confirmed myocardial infarction, but it is not the first priority for the nurse. Cardiac catheterization is an invasive procedure that involves inserting a catheter into a large artery and advancing it to the coronary arteries to visualize any blockages or stenosis. The procedure may also involve angioplasty or stent placement to restore blood flow to the affected area.
• Request a prescription for an increase in statin: This may be a long-term intervention to lower the client’s LDL cholesterol and prevent further plaque formation in the coronary arteries, but it is not an immediate intervention for chest pain. Statins are lipid-lowering drugs that can reduce the risk of cardiovascular events in clients with CAD, but they do not have a direct effect on chest pain or myocardial ischemia.
• Check a STAT cardiac troponin: This may be a diagnostic test to confirm or rule out a myocardial infarction, but it is not an intervention for chest pain. Cardiac troponin is a protein that is released into the bloodstream when there is damage to the heart muscle. Elevated levels of cardiac troponin indicate a myocardial infarction or other cardiac injury.
• Request a prescription for a beta-blocker: This may be an adjunctive therapy to reduce chest pain and prevent complications, but it is not the first-line intervention for chest pain. Beta-blockers are drugs that block the effects of adrenaline on the heart and blood vessels, which can lower heart rate, blood pressure, and myocardial oxygen demand. Beta-blockers can also prevent arrhythmias and reduce mortality in clients with CAD.
Correct Answer is C
Explanation
Wound dehiscence can lead to infection, bleeding, and evisceration (protrusion of internal organs through the incision). The nurse should report this finding to the provider immediately and cover the wound with a sterile dressing moistened with sterile saline solution.
Choice A is wrong because mild swelling under the sutures near the incisional line is a normal finding in the early stages of wound healing. It does not indicate infection or dehiscence unless accompanied by other signs such as redness, warmth, pain, or purulent drainage.
Choice B is wrong because crusting of exudate on the incisional line is also a normal finding that indicates the formation of a scab.
A scab protects the wound from infection and helps it heal faster. The nurse should not remove the scab unless instructed by the provider.
Choice D is wrong because pink-tinged coloration on the incisional line is another normal finding that shows healthy granulation tissue.
Granulation tissue is new tissue that fills in the wound and helps it close. It is usually pink or red and moist.
The nurse should follow these general tips for postoperative abdominal incision care:
- Always wash your hands before and after touching your incisions.
- Inspect your incisions and wounds every day for signs your healthcare provider has told you are red flags or concerning.
- Look for any bleeding.
If the incisions start to bleed, apply direct and constant pressure to the incisions.
- Avoid wearing tight clothing that might rub on your incisions.
- Try not to scratch any itchy wounds.
- You can shower starting 48 hours after your operation but no scrubbing or soaking of the abdominal wounds in a tub.
- After the initial dressing from the operating room is removed, you can leave the wound open to air unless there is drainage or you feel more comfortable with soft gauze covering the wound.
- Surgical glue (Indermil) will fall off over a period of up to 2-3 weeks.
Do not put any topical ointments or lotions on the incisions.
- Do not rub over the incisions with a washcloth or towel.
- No tub baths, hot tubs, or swimming until evaluated at your clinic appointment.
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