Practice Question
A nurse is supervising a newly licensed nurse who is caring for a client on a behavioral health unit.
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Rationale:
✔ When a client is placed in seclusion, immediate safety becomes the highest priority, particularly on a behavioral health unit where escalation can lead to injury.
- Continuous monitoring must begin as soon as the intervention is implemented to ensure the client’s physical and psychological well-being and to detect early signs of deterioration.
✔ Seclusion is a restrictive intervention and must follow strict legal and ethical guidelines. Although a provider’s order is required, emergency use can be initiated by a nurse—but must then be followed by obtaining a formal order as soon as possible, typically within 1 hour.
✔ The Joint Commission and CMS guidelines require that clients in seclusion or restraints are monitored continuously—this includes assessing vital signs, level of distress, and ensuring their basic needs (hygiene, nutrition, toileting) are met.
✔ The correct sequencing ensures that immediate patient safety and observation are prioritized first, and then the legal procedural requirement of obtaining an order is completed to validate the intervention.
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This question is from RN Nur2508 Leadership Final Exam which contains 118 questions.
More Questions from This Exam
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Leadership & Management
- Answer Choices: 0