A client has been placed in seclusion. Which client behavior ...

[pragya sharda]

A client has been placed in seclusion. Which client behavior would have warranted this intervention?
 
  1. The client is manic, has been flirtatious towards staff and refused morning medication, and has verbalized a plan to leave
  2. The client is psychotic, sits in the corner with hands over ears, and displays increased suspiciousness of and agitation towards others despite recently receiving 1mg risperidone (Risperdal) PRN
  3. The client is depressed and wants to be left alone to rest
  4. The client is suicidal, has been banging head against the table in the day room, and was unresponsive to staff's verbal redirection

Question 2

A client with paranoid schizophrenia is experiencing visual hallucinations of people jumping out of nowhere. The client keeps striking the wall.
 
  Repeated attempts by the nurse to orient the client to reality and reassure the client of safety have failed. What would be the nurse's next de-escalation approach? 1. Offer the client a PRN medication
  2. Apply soft limb restraints on client's wrists
  3. Have several staff demobilize the client so that forcible injection can be administered
  4. Call security to assist in placing the client in seclusion

[Kimmy]

Answer to Question 1

2
Rationale: The scientific rationale for the use of seclusion is based on three principles: containment, isolation, and decrease in sensory input. This client exhibits behavior that suggests increased sensitivity to the environment and risk of harm to others. A less restrictive measure has been tried (medication) without success. Seclusion should not be used as punishment for inappropriate behavior or to prevent client elopement. Seclusion is inappropriate when a client is engaging in self-injurious behavior that could continue in the seclusion environment (head-banging); in such circumstances a 1:1 staffing or restraints may be necessary. If a client seeks isolation voluntarily, seclusion (locking the door) is not warranted.

Answer to Question 2

1
Rationale: Offering the client a PRN medication would be the next step as attempts at verbal de-escalation have failed. Restraints are the most restrictive intervention and not warranted at this point. Seclusion will not prevent the client from self-harm inflicted by beating the walls. Forcing medication is a chemical restraint and not warranted until voluntary medication has been refused.