A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "Wow! You have big breasts."
Which response is best for the PN to provide?
The size of my breasts is of no concern to you.
That language is not allowed.
Do you really think so?
If you talk like that again, I will tell your parents.
The Correct Answer is B
This is the best response for the PN to provide because it sets a clear and firm boundary for the adolescent and discourages inappropriate or sexual comments. The PN should also redirect the adolescent's atention to another topic or activity and document the incident.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A thready pulse is a weak and rapid pulse that is easily obliterated by light pressure. It indicates poor blood flow and perfusion, and may be caused by conditions such as shock, dehydration, or hemorrhage.
The other options are not correct because:
- A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood flow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.
- Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
- Pulse skips beats is a documentation of an irregular pulse rhythm, not a pulse volume. It indicates that the heart beats are unevenly spaced, and may be caused by conditions such as arrhythmia, stress, or caffeine intake.
Correct Answer is A
Explanation
This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.

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