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Practice Question

A nurse is supervising a newly licensed nurse who is caring for a client on a behavioral health unit.

Answer Choices:

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
A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

Answer Choices:

A. "The client works in the hospital radiology department"
B. "The client discussed having prior thoughts of suicide."
C. "The client's blood pressure and pulse have been fluctuating throughout the day."
D. "The client's family members have been present most of the day."
A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first?

Answer Choices:

A. Report the observation to the nurse caring for that client
B. Inform the nursing supervisor
C. Approach the man and ask why he is making copies.
D. Notify hospital security
A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities canthe nurse assign to the AP? (Select all that apply.)

Answer Choices:

A. Check the position of a client in soft wrist restraints_
B. Accompany a client who has depression to occupational therapy.
C. Set limits with a client who has mania.
D. Sit with a client who has alcohol use disorder and whose last drink was five days ago.
E. Assess a client who has hypomania for exhaustion.
A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.)

Answer Choices:

A. Ambulate an older adult client who has hypertension.
B. Provide discharge instructions for a client who has a new skin graft.
C. Check a blood product with another nurse prior to administration.
D. Weigh a client who has heart failure.
E. Perform an admission assessment on a client.
From Exam
RN Nur2508 Leadership Final Exam

118 Questions

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Question Details
  • Category: RN Nursing Exam(s)
  • Subcategory: ATI Exam(s)
  • Domain: RN ATI Leadership & Management
  • Answer Choices: 0
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