# Situation: A 36-year-old man with schizophrenia is on a psychiatric ward that uses an electronic health record (EHR). Nurses write focus charting notes, and the treatment team writes SOAPIE progress notes (Subjective, Objective, Assessment, Plan, Intervention, Evaluation). This morning he threw chairs in the dayroom and was placed in seclusion on the order of the attending psychiatrist. Per unit protocol, the written release criteria for seclusion are: calm for 30 continuous minutes, following staff directions, and no threats during those 30 minutes. The observation record reads: 10:50 Shouting, kicking the door 11:05 Sitting quietly; drinks water when asked 11:20 Sitting quietly; says, "When I get out, that nurse will pay." 11:35 Sitting quietly; sits on the mat when asked 11:40 Asks calmly to be let out Which entry should the nurse make at 11:40?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630253  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 36-year-old man with schizophrenia is on a psychiatric ward that uses an electronic health record (EHR). Nurses write focus charting notes, and the treatment team writes SOAPIE progress notes (Subjective, Objective, Assessment, Plan, Intervention, Evaluation). This morning he threw chairs in the dayroom and was placed in seclusion on the order of the attending psychiatrist.

Per unit protocol, the written release criteria for seclusion are: calm for 30 continuous minutes, following staff directions, and no threats during those 30 minutes. The observation record reads:
10:50 Shouting, kicking the door
11:05 Sitting quietly; drinks water when asked
11:20 Sitting quietly; says, "When I get out, that nurse will pay."
11:35 Sitting quietly; sits on the mat when asked
11:40 Asks calmly to be let out
Which entry should the nurse make at 11:40?

## 보기

1. 11:40 Seclusion continued; threat at 11:20, criteria unmet **✔ 정답**
2. 11:40 Released; calm 35 minutes and following directions
3. 11:40 Moved to the dayroom on one-to-one observation
4. 11:40 Released; asks calmly, and the threat was not repeated

**정답: 1**

## 해설

All three criteria must hold for the same 30 minutes. He has been sitting quietly since 11:05 (35 minutes) and follows directions, but he voiced a threat at 11:20, only 20 minutes earlier, so the no-threat criterion is not yet met. The nurse continues seclusion, records the reason, and reassesses.

## 심화 해설

Applying the release criteria
The written release criteria require that the client be calm for 30 continuous minutes, following staff directions, and making no threats during those 30 minutes. All three must hold for the same 30-minute period. He has been sitting quietly since 11:05 (35 minutes) and follows directions, but at 11:20 he said, "When I get out, that nurse will pay." At 11:40, only 20 minutes have passed since that threat. The no-threat criterion is not yet met, so seclusion continues, and the entry records the reason.

Working through the timeline
Laying out the record shows exactly where each criterion stands at 11:40.

| Time | Observation | Effect on criteria |
| --- | --- | --- |
| 10:50 | Shouting, kicking the door | Not calm |
| 11:05 | Sitting quietly; drinks water when asked | Calm period begins; follows directions |
| 11:20 | Sitting quietly; threatens a nurse | No-threat clock restarts |
| 11:35 | Sitting quietly; sits on mat when asked | Calm; follows directions |
| 11:40 | Asks calmly to be let out | Calm 35 min, but only 20 min without threats: criteria unmet |

Why the other entries are wrong
Releasing him because he has been calm for 35 minutes and follows directions uses only part of the rule; the threat at 11:20 means the 30-minute no-threat period is incomplete. Releasing him because he asks calmly and has not repeated the threat ignores the required time; 20 minutes is less than 30, and a calm request does not override the criteria. Watch out! Moving him to the dayroom on one-to-one observation sounds like a compromise, but it ends seclusion, and closer observation does not replace an unmet criterion.

Seclusion principles
Seclusion is a restrictive intervention used only when less restrictive measures have failed and there is imminent danger. It is ended as soon as the client meets release criteria, so the nurse reassesses frequently and tells the client what he needs to do to be released, for example, "When you have been calm and without threats until 12:00, we will review." The nurse continues to offer fluids, toileting, and monitoring of physical and emotional status. Consistent use of written criteria protects both the client's rights and staff safety.

Exam takeaway
Key point! Release criteria are applied together over the same time window. A single threat restarts the no-threat clock. Document the specific unmet criterion and the plan to reassess.

## 임상 시나리오

Seclusion Release CriteriaChecking all three criteria in the same 30 minutes
Criteria: calm for 30 continuous minutes, following directions, and no threats during those 30 minutes. All must be met together.

He has been calm since 11:05, but he threatened a nurse at 11:20. At 11:40, only 20 minutes have passed without threats, so seclusion continues.

Record the unmet criterion, tell him what is needed for release, and reassess frequently while meeting fluid, toileting, and comfort needs.

CautionMoving him to the dayroom on one-to-one observation ends seclusion; closer observation does not replace an unmet release criterion.

## 핵심 개념

- **Seclusion** — Involuntary confinement of a client alone in a room to prevent imminent harm.
- **Release criteria** — Written behavioral standards that must be met before seclusion or restraint is ended.
- **Least restrictive intervention** — The measure that ensures safety while limiting the client's freedom as little as possible.
- **Reassessment** — Repeated evaluation of the client to decide whether a restrictive measure is still needed.
- **One-to-one observation** — Continuous observation of a client by a staff member assigned only to that client.

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