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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Free Nursing Study Resources

Correct Answer is B

No explanation

A. A client who has bipolar disorder and is speaking loudly. B. A client who is taking lithium and reports weight gain. C. A client who is taking clozapine and reports a sore throat. D. A client who has schizophrenia and is experiencing olfactory hallucinations.

Correct Answer is C

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

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