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

The correct answer is Choice C: Determine the immediate safety needs of the child.

Choice A rationale: Reporting suspected abuse to Child Protective Services is an important step in cases of suspected child abuse. However, before taking this action, it is crucial to ensure the immediate safety and well-being of the child. Jumping directly to reporting without assessing the immediate safety needs could potentially put the child at further risk if they are left in a dangerous situation. Therefore, while reporting suspected abuse is necessary, it is not the first action the nurse should take in this scenario.

Choice B rationale: Requesting that the parent leave the room while interviewing the child may be necessary to ensure the child feels comfortable and able to speak freely. However, before conducting the interview, it is essential to address any immediate safety concerns. Additionally, removing the parent from the room may not always be feasible or appropriate, especially if the child requires immediate medical attention or protection. Therefore, while this action may be taken at some point, it is not the first action the nurse should take.

Choice C rationale: Determining the immediate safety needs of the child is the first and most critical action the nurse should take in this scenario. This involves assessing the severity of the injury, evaluating if the child is in immediate danger, and taking any necessary steps to ensure their safety and well-being. This could include providing medical treatment, removing the child from a dangerous environment, or contacting emergency services if needed. By addressing the immediate safety needs first, the nurse can ensure the child's well-being before further investigating the situation.

Choice D rationale: Asking the child how the injury occurred is an important step in gathering information about the incident. However, before conducting the interview, it is essential to prioritize the child's safety and well-being. Jumping directly to questioning without assessing the immediate safety needs could potentially further traumatize the child or put them at risk if they are in a dangerous situation. Therefore, while interviewing the child is necessary, it should not be the first action taken by the nurse.

In conclusion, Choice C, determining the immediate safety needs of the child, is the first action the nurse should take in this scenario to ensure the child's well-being and safety are prioritized.

A. The father who intervenes whenever the siblings argue. B. The adolescent daughter who attempts to dominate the discussion. C. The adolescent son who refuses to share personal feelings. D. The mother who expresses hostility toward her spouse.

Correct Answer is B

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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Explanation

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