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 D
Explanation
This is because after puncturing the skin and the vein, the nurse needs to advance the catheter into the vein with the finger hub to ensure proper placement and prevent complications such as infiltration or phlebitis.
Choice A is wrong because flushing the catheter with saline should be done after securing the catheter to the skin with a transparent dressing and attaching a primed piece of extension tubing to the catheter.
Choice B is wrong because retracting the stylet should be done after advancing the catheter into the vein and releasing the tourniquet from the client’s arm.
Choice C is wrong because releasing the tourniquet should be done after advancing the catheter into the vein and before retracting the stylet.
Correct Answer is A
Explanation
Encourage collaboration between the two nurses when making the assignments. This is because collaboration is one of the most effective conflict-resolution strategies in nursing, as it involves finding a mutually beneficial solution that satisfies both parties and improves the quality of care. Collaboration can also foster trust, respect, and teamwork among nurses, which can boost morale and efficiency.
Choice B is wrong because telling the nurses that the assignments will be more equitable in the future does not address the root cause of the conflict or involve the nurses in the decision-making process.
It also implies that the charge nurse admits to being unfair, which can damage their credibility and authority.
Choice C is wrong because asking each nurse to take turns making the assignments does not resolve the conflict, but rather avoids it. Avoidance is one of the least effective conflict management strategies in nursing, as it results in not addressing the issue or finding a common ground.
Avoidance can also lead to resentment, frustration, and poor communication among nurses.
Choice D is wrong because arranging for the nurses to have as few shifts together as possible also does not resolve the conflict, but rather accommodates it. Accommodation is another ineffective conflict management strategy in nursing, as it involves giving in to one party’s demands or preferences at the expense of another’s.
Accommodation can also create a sense of inequality, injustice, and dissatisfaction among nurses.
Normal ranges for conflict-resolution strategies in nursing are not applicable, as different situations may require different approaches.
However, some general guidelines are to use collaboration when both parties have important goals or interests, compromise when both parties have some common ground or willingness to give up something, competition when one party has a clear advantage or authority, avoidance when the conflict is trivial or temporary, and accommodation when one party values harmony or relationships more than their own goals or interests.
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