Question

a nurse is caring for an adult client who is experiencing mania and is placed in seclusion due to escalating behavior. which of the following actions should the nurse take?

• request that the provider assess the client within 8 hr.
• discontinue the seclusion if the client requests it.
• document the client’s behavior every 15 min while in seclusion.
• request a prn prescription for future seclusion.

Explanation:

To solve this, we analyze each option based on nursing standards for seclusion:

• Option 1: Providers assess seclusion clients regularly, but the time frame and "despair" wording are incorrect.
• Option 2: Seclusion is for safety; discontinuing on client request violates protocol.
• Option 3: Documentation of behavior every 15 minutes is a standard nursing action to monitor the client’s status during seclusion.
• Option 4: PRN prescriptions for seclusion are not standard; seclusion is for immediate safety, not routine PRN use.

Answer:

C. Document the client’s behavior every 15 min while in seclusion.