During an episode of acute mania a newly admitted client who is displaying hyperactive, restless,
and disorganized behavior goes into the dining room and begins to throw food and dishes.
Verbal
intervention is ineffective and seclusion is instituted. The items of documentation that should be
included in the medical record include (more than one answer may be correct)
A. 1750: Client entered dining room and began to shout and randomly throw food and dishes at
walls and other clients.
B. Continued to throw items despite limit setting and verbal redirection. Client refused to leave
dining room.
C. Client's behavior determined to pose a substantial risk of harm to others. Client escorted to
seclusion without a struggle by four staff.
D. Seclusion explained. Harmful items removed from room and person per unit protocol.
E. 1800: prn lorazepam (Ativan) administered IM.
F. 1815: Vital signs: blood pressure, 120/85 mm Hg; pulse, 90 beats/min; respirations, 22
breaths/min. Client lying on mattress. Chanting profanity.