During an episode of acute mania a newly admitted client who is displaying hyperactive, restless,
and disorganized behavior goes into the dining room and begins to throw food and dishes.
Verbal
intervention is ineffective and seclusion is instituted. The items of documentation that should be
included in the medical record include (more than one answer may be correct)
A. 1750: Client entered dining room and began to shout and randomly throw food and dishes at
walls and other clients.
B. Continued to throw items despite limit setting and verbal redirection. Client refused to leave
dining room.
C. Client's behavior determined to pose a substantial risk of harm to others. Client escorted to
seclusion without a struggle by four staff.
D. Seclusion explained. Harmful items removed from room and person per unit protocol.
E. 1800: prn lorazepam (Ativan) administered IM.
F. 1815: Vital signs: blood pressure, 120/85 mm Hg; pulse, 90 beats/min; respirations, 22
breaths/min. Client lying on mattress. Chanting profanity.
A, B, C, D, E, F
Rationale: All items should be included in the medical record. Options A and B provide essential
information explaining the client's behavior and need for the environmental simplification provided
by seclusion. Option C provides a rationale for seclusion and describes the process of secluding the
client. Option D reiterates elements of the agency protocol designed to support client psychosocial
and biophysical safety. Option E documents medication administration. Option F documents client
physical status and behavior.
You might also like to view...
A patient weighing 65 kg has a deep partial-thickness burn that totals 45% total body surface area (TBSA) and is ordered to receive fluid resuscitation with volumes calculated by the maximum amount from the American Burn Association consensus formula
. The burn occurred at 0800 and intravenous fluids are initiated at 1000 . For the first 8 hours after the burn, the nurse plans to administer what amount of intravenous lactated Ringer's solution in mL/hr?
The nurse can assist with reducing anxiety when preparing a patient for a diagnostic examination by:
a. explaining the costs of the examination. b. demonstrating use of equipment. c. answering questions for clarification. d. filling out required paperwork.
Which form of massages releases chronic patterns of tension using slow strokes and deep finger pressure on contracted areas?
a. Swedish massage c. Sports massage b. Trigger-point mas-sage d. Deep tissue and fric-tion massages
A newly diagnosed type 1, well-controlled, insulin-dependent diabetic client at 20 weeks' gestation asks the nurse how her diabetes will affect her baby. The best explanation would include:
1. "Your baby might be smaller than average at birth." 2. "Your baby will probably be larger than average at birth." 3. "As long as you control your blood sugar, your baby will not be affected at all." 4. "There are no effects until about 2 hours after birth, when your baby might have low blood sugar."