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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
The correct answers are B and C.
Choice A Reason: Transferring a client who is receiving radiation therapy involves understanding the precautions and care associated with radiation, which may be beyond the training of assistive personnel (AP). Radiation therapy clients may have specific safety and transport protocols that require the expertise of licensed nursing staff.
Choice B Reason: Measuring vital signs for a client who requires contact precautions is a task that can be delegated to AP. Assistive personnel can be trained in infection control procedures and the use of personal protective equipment (PPE), making them capable of measuring vital signs while adhering to contact precautions.
Choice C Reason: Recording urine output for a client who has a suprapubic catheter can be delegated to AP. This task involves measuring and documenting a quantifiable data point, which does not require the clinical judgment of a nurse. AP can be trained to accurately measure and record urine output.
Choice D Reason: Planning care for a client who has dysphagia is a complex task that involves assessment and clinical judgment, which are responsibilities of the licensed nurse. Dysphagia can have serious complications, and care plans must be tailored to each client’s needs, requiring the expertise of a nurse.
Correct Answer is B
Explanation
The correct answer is B.
Assist the adolescent in applying for Medicaid.
This action demonstrates the nurse’s role as an advocate and a resource person for the client, who might be eligible for financial assistance and health care coverage during her pregnancy and postpartum period. Medicaid is a federal and state program that provides health insurance for low-income individuals and families.
Choice A is wrong because contacting the adolescent’s parent for assistance might violate the client’s confidentiality and autonomy, especially if the parent is not aware of or supportive of the pregnancy. The nurse should respect the client’s right to privacy and self-determination, unless there is a risk of harm to the client or the fetus.
Choice C is wrong because referring the adolescent to a local mental health clinic might imply that the client has a mental disorder or needs psychological counseling, which could be stigmatizing and discouraging.
The nurse should assess the client’s emotional state and coping skills, and provide supportive and nonjudgmental care. The nurse can also offer referrals to other community resources, such as prenatal education, parenting classes, or social services, that might benefit the client.
Choice D is wrong because advising the adolescent to place the newborn for adoption might interfere with the client’s decision-making process and personal values.
The nurse should not impose his or her own opinions or beliefs on the client, but rather explore the client’s feelings and preferences about her pregnancy options. The nurse should provide factual information and education about adoption, abortion, or parenting, and help the client weigh the benefits and risks of each option.
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