A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?
A school-age client who attempts to repeatedly bite staff.
An older adult client who is manic and agitated due to overstimulation.
An adolescent client who throws objects at other clients.
An adult client after an interrupted suicide attempt.
The Correct Answer is D
Choice A rationale:
Seclusion may be considered for a school-age client who repeatedly bites staff as a method of last resort to ensure the safety of both the client and staff.
It's important to exhaust other interventions first, such as verbal de-escalation, redirection, and medication.
If seclusion is used, it should be implemented under strict guidelines, with close monitoring and frequent reassessment to determine its effectiveness and necessity.
Choice B rationale:
Seclusion may be considered for an older adult client who is manic and agitated due to overstimulation, as it can provide a safe and quiet environment to reduce sensory input and promote calming.
However, it's crucial to carefully assess the client's physical and cognitive status, as seclusion can exacerbate confusion and disorientation in older adults.
Close monitoring and reassessment are essential.
Choice C rationale:
Seclusion may be considered for an adolescent client who throws objects at other clients to maintain safety and prevent harm to others.
It's important to first attempt other interventions, such as verbal de-escalation, redirection, and limit-setting.
If seclusion is used, it should be brief and implemented with therapeutic goals in mind, such as promoting self-regulation and problem-solving skills.
Choice D rationale:
Seclusion is contraindicated for an adult client after an interrupted suicide attempt.
This is because seclusion can increase isolation, hopelessness, and despair, which are significant risk factors for suicide.
It can also hinder close observation and monitoring of the client's mental state, potentially leading to further suicide attempts.
Instead, the focus should be on providing supportive, one-to-one contact, ensuring safety, and establishing therapeutic rapport to address the underlying issues that led to the suicide attempt.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. “St. John’s wort can reduce the effectiveness of oral contraceptives.”
Choice A rationale:
St. John’s wort is commonly used to treat mild to moderate depression. It has been shown to be effective in alleviating symptoms of depression, likely due to its impact on neurotransmitters like serotonin.
Choice B rationale:
There is no evidence to suggest that St. John’s wort can lower prostate-specific antigen (PSA) levels. PSA levels are typically monitored for prostate health, and St. John’s wort does not have an impact on these levels.
Choice C rationale:
St. John’s wort does not increase estrogen levels in the body. It primarily affects neurotransmitters and has no known effect on hormone levels.
Choice D rationale:
St. John’s wort can indeed reduce the effectiveness of oral contraceptives. It induces certain liver enzymes that can increase the metabolism of contraceptive hormones, thereby reducing their effectiveness and increasing the risk of unintended pregnancy.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale:
Altered body image is a hallmark feature of eating disorders. Individuals with eating disorders often have a distorted perception of their bodies, believing they are overweight or larger than they actually are. This distorted body image can lead to intense dissatisfaction with their appearance, even when they are underweight. They may engage in obsessive behaviors such as repeatedly checking their weight, measuring their body parts, and avoiding mirrors. They may also fixate on perceived flaws in their appearance, leading to significant distress and impairment in their daily lives.
Choice B rationale:
Amenorrhea, the absence of menstruation, is a common physiological consequence of eating disorders. It occurs due to hormonal imbalances caused by insufficient intake of calories and nutrients, particularly fat. The body requires a certain amount of body fat to maintain normal reproductive function. When body fat levels fall below a critical threshold, the hypothalamus, a part of the brain that regulates hormone production, signals the pituitary gland to reduce the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). These hormones play crucial roles in ovulation and menstruation. Without adequate levels of FSH and LH, ovulation and menstruation do not occur.
Choice C rationale:
Hyperactivity, characterized by excessive energy and restlessness, can manifest in individuals with eating disorders. This increased activity level may be a way to burn calories or compensate for perceived overeating. It may also be a way to distract themselves from thoughts about food and body image. The hyperactivity can present in various forms, such as excessive exercise, fidgeting, or constant movement.
Choice D rationale:
Bradycardia, a slower-than-normal heart rate, is another physiological sign that can accompany eating disorders. It occurs as the body attempts to conserve energy in response to inadequate caloric intake. The heart rate slows down to minimize energy expenditure. Bradycardia can have serious health implications, including fatigue, dizziness, fainting spells, and potentially life- threatening heart arrhythmias.
Choice E rationale:
Verbalized desire to gain weight is not a typical manifestation of eating disorders. Individuals with eating disorders often have a strong fear of weight gain and a persistent drive for thinness. They may actively resist efforts to increase their weight, even when they are dangerously underweight.
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