A nurse is caring for a client who requires seclusion to prevent harm to others on the unit.
Which of the following is an appropriate action for the nurse to take?
A.
Discuss with the client his inappropriate behavior prior to seclusion
B.
Offer fluids every 2 hr.
C.
Document the client’s behavior prior to being placed in seclusion.
D.
Assess the client’s behavior once every hour.
The Correct Answer and Explanation is:
The correct answer is:
C. Document the client’s behavior prior to being placed in seclusion.
Explanation:
Seclusion is a restrictive intervention used as a last resort to manage a client’s behavior when they pose a threat to themselves or others. The decision to use seclusion must be carefully considered and is subject to strict regulatory and ethical guidelines. Proper documentation before and during seclusion is essential to ensure that the intervention is justified, legal, and conducted in the client’s best interest.
Option C: Document the client’s behavior prior to being placed in seclusion is the correct action. Documentation is crucial because it provides a detailed record of the client’s behavior, which justifies the need for seclusion. This documentation must include the specific actions or behaviors that led to the decision to place the client in seclusion. It serves as a legal record and is vital for reviewing the appropriateness of the intervention. Documentation also helps in communicating the client’s condition to other healthcare providers and is necessary for quality assurance and regulatory compliance.
Option A: Discuss with the client his inappropriate behavior prior to seclusion is not the most appropriate action at the time of seclusion. While discussing behavior and providing feedback are essential aspects of care, during a crisis that necessitates seclusion, the immediate focus should be on ensuring safety rather than engaging in a discussion that may escalate the situation.
Option B: Offer fluids every 2 hr is important for maintaining the client’s physical well-being while in seclusion, but it is not the first priority when placing a client in seclusion. Offering fluids is a part of ongoing care during seclusion, ensuring the client’s basic needs are met, but does not address the immediate action of documenting behavior.
Option D: Assess the client’s behavior once every hour is a necessary part of monitoring the client while they are in seclusion, ensuring their safety and determining when seclusion can be safely discontinued. However, the question asks for the action to take prior to seclusion, making documentation the correct first step.
In conclusion, documentation of the client’s behavior before initiating seclusion is the most appropriate action. It provides a legal and ethical foundation for the intervention, ensures accountability, and supports the safety and rights of the client. This documentation should be thorough, objective, and completed promptly to protect both the client and the healthcare providers involved in the intervention.