A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

Document the client's behavior every 15 min.

Obtain the provider's prescription within 60 min.

Offer the client food and fluids every 2 hr.

Monitor the client's vital signs every 4 hr.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Documenting the client's behavior every 15 minutes is a valid nursing action when a client is placed in seclusion. However, it is not the most critical step to take in this situation. The safety and well-being of the client and staff are paramount, and obtaining the provider's prescription is more crucial.

Choice B rationale:

The correct choice. Obtaining the provider's prescription within 60 minutes is essential when a client is placed in seclusion. Seclusion is an intervention that restricts the client's freedom, and it should only be done under the supervision of a licensed healthcare provider. The nurse must obtain a prescription for this intervention as soon as possible to ensure that the client's rights and safety are respected.

Choice C rationale:

Offering the client food and fluids every 2 hours is a valid nursing action in a seclusion situation. However, it is not the most immediate priority. Obtaining the provider's prescription takes precedence to ensure the appropriateness of the intervention.

Choice D rationale:

Monitoring the client's vital signs every 4 hours is an important nursing action, but it is not the primary step to take immediately after placing a client in seclusion. Obtaining the provider's prescription is more urgent to ensure the legality and appropriateness of the intervention.

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Correct Answer is C

Explanation

Choice A rationale:

While it's true that many people feel ashamed to tell their secrets, this response does not actively encourage the client to open up about their feelings. It acknowledges the feeling but does not promote a therapeutic conversation.

Choice B rationale:

Encouraging the client to tell the nurse what they did might not be the most appropriate response. The client might not be ready to disclose their actions and pushing them to do so could lead to further distress. It's important to establish trust and create a safe space for the client before delving into specific details.

Choice C rationale:

The correct choice. This response is empathetic and supportive while also gently encouraging the client to discuss their feelings. It opens the door for the client to share at their own pace and lets them know that the nurse is willing to listen without judgment.

Choice D rationale:

While it's true that the client shouldn't feel embarrassed to talk to the nurse, this response doesn't actively address the client's feelings or concerns. It's more important to provide a response that acknowledges the client's emotions and invites open communication.

A. Impaired memory. B. Rapid mood swings. C. Inappropriate speech patterns. D. Command hallucinations. E. Command hallucinations.

Correct Answer is D

No explanation

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A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is D

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