A psychiatric patient who is experiencing paranoid delusions appears increasingly agitated. She accepts PRN olanzapine (Zyprexa), but she states that she feels unsafe on the unit and has urges to hurt her roommate. She agrees to utilize seclusion while the medication takes effect. Which of the following is an appropriate nursing action?


•The nurse should lock the seclusion door if the patient is expressing urges to hurt another patient and she is agitated and paranoid. The nurse must assign a mental health worker to continuously watch the patient on the monitor. This is required. A patient may never be left unattended in seclusion or 4-point restraints due to the risk of injury.

•Due to the patient's paranoia, watching the patient on the monitor is preferred over watching through the window, which could increase her agitation.

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