A client became aggressive, struck another client, and required seclusion. The best documentation is
a. "Client apparently doesn't like client X, as evidenced by his striking client X
when client attempted to leave day room to go to bathroom. Seclusion necessary
at 2:15 PM. Plan: Maintain seclusion for 8 hours and keep this client and client X
away from each other for 24 hours.".
b. "Seclusion ordered by Dr. at 2:15 PM when voices told the client to hit another
client.".
c. "Client pacing, shouting at people not present in the environment.
Chlorpromazine 50 mg administered po at 1 PM with no effect by 2 PM. At 2:15
PM client shouted that he would punch the first person who got near him, then
struck client X on the jaw with his fist as client X walked out of day room to go to
bathroom. Client physically restrained by staff and placed in seclusion by order of
Dr. Y.".
d. "Seclusion ordered by Dr. Y for aggressive behavior, begun at 2:15 PM.
Maintained for 2 hours without incident. Outcome: Client calmer.".
ANS: C
Option A introduces the nurse's subjective views. Options B and D do not include necessary details.
Documentation should include a description of behavior and verbalizations, interventions tried and
their outcomes, and the name of the physician ordering the use of seclusion.
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