A client became aggressive, struck another client, and required ...

[iveyjurea]

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..

Question 2

A client referred to the eating disorders clinic has lost 35 pounds during the summer and has
  developed amenorrhea.
 
  Physical manifestations of anorexia nervosa for which the nurse should
  assess include (more than one answer may be correct)
  A. peripheral edema.
  B. parotid swelling.
  C. constipation.
  D. hypotension.
  E. dental caries.
  F. lanugo.

[robbielu01]

Answer to Question 1

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.

Answer to Question 2

A, C, D, F
Rationale: Peripheral edema is often present because of hypoalbuminemia. Constipation related to
starvation is often present. Hypotension is often present because of dehydration. Lanugo is often
present and is related to starvation. Option B: Parotid swelling is associated with bulimia. Option E:
Dental caries are associated with bulimia.