A client who is in active labor is admitted with her cervix dilated to 3 cm with 50% eﬀacement and the presenting part at 0 station. An hour later, she tells the practical nurse (PN) that she wants to go to the bathroom to empty her bladder. The nurse examines the client again and determines her vaginal exam is unchanged.

Which action should the PN implement?

Review the fetal heart rate pattern.

Assist the client up to the bathroom.

Check perineum for changes in "show" or discharge.

Obtain a straight catheter kit to empty her bladder.

Answer and Explanation

The Correct Answer is B

If the client in active labor expresses a desire to empty her bladder and her vaginal exam is unchanged, the practical nurse (PN) should assist her up to the bathroom. An empty bladder can help facilitate labor progress.

Reviewing the fetal heart rate pattern (A) is important, but it is not the most appropriate action in response to the client's request to empty her bladder. Checking the perineum for changes in "show" or discharge (C) is also important, but it is not the most appropriate action in this situation. Obtaining a straight catheter kit to empty the client's bladder (D) may be necessary if she is unable to empty her bladder on her own, but assisting her up to the bathroom should be attempted first.

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Correct Answer is B

Explanation

This is the most appropriate intervention for the PN to implement when approaching a client who is exhibiting compulsive behavior. By allowing time for the behavior, the PN acknowledges the client's need to perform the behavior and avoids creating further stress for the client. Redirecting the client to other activities can also help to refocus the client's behavior and prevent further compulsive behavior.

Encouraging the client to be calm and relax for a little while (A) may not be eﬀective in managing the compulsive behavior.

Teaching the client thought-stopping techniques and ways to refocus behaviors (C) and assisting the client to identify stimuli that precipitate the activity (D) are interventions that may be used in the long term, but they may not be immediately eﬀective in managing the client's behavior in the moment.

A. Delay administration of nighttime medications until after visitors have left. B. Administer a prescribed PRN benzodiazepine at the onset of a confused state. C. Make certain that the client's assigned room is close to the nurses' station. D. Ask family members about how they dealt with the client in the evening.

Correct Answer is C

Explanation

Restlessness, confusion, and agitation are common symptoms of dementia, particularly in the evening, a phenomenon known as sundowning. Therefore, the PN should implement interventions that can help to prevent or minimize these symptoms. Assigning the client to a room close to the nurses' station can help to provide constant observation and reassurance and can help to prevent the client from wandering or becoming disoriented.
A. Delaying administration of nighttime medications until after visitors have left may be appropriate, but it is not the first intervention to be implemented in this scenario.
B. Administering a prescribed PRN benzodiazepine at the onset of a confused state may be appropriate in some cases, but it should not be the first intervention to be implemented in this scenario.
D. Asking family members about how they dealt with the client in the evening may be helpful, but it is not the first intervention to be implemented in this scenario.

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Naxlex Comprehensive Predictor Exams

During morning rounds, a client who is admitted with obsessive-compulsive disorder is in the dayroom repeatedly washing the top of the same table. Which intervention should the practical nurse (PN) implement when approaching the client?

Correct Answer is B

Explanation

An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention should the PN implement?

Correct Answer is C

Explanation

A 4-year-old girl is brought to the emergency room with a fractured arm. Which information should be a basis for the practical nurse (PN) to suspect child abuse?

A patient is admitted to the postpartum unit one hour after a sterile vaginal delivery of a normal neonate weighing 8 pounds 2 ounces (3.7 kg). When the client's fundus becomes boggy and displaced above the umbilicus, which action should the practical nurse (PN) take first?

A client who is a primigravida at 40 weeks gestation is contracting every 2 minutes and her cervix is 9 cm dilated and 100% eﬀaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the practical nurse (PN) implement?

A mother calls the clinic to report that her child has just swallowed "poison" and is vomiting. In preparing to instruct the mother about the necessary action to take, which substance should the practical nurse (PN) consider to be the least traumatic to the esophagus when the child vomits?

The practical nurse (PN) is interviewing a middle-aged married male who is being treated for depression and reports an increasing lack of interest in sexual intimacy with his wife. Which information is most important for the PN to obtain?

A postpartum client who delivered vaginally 6-hours ago and had a second-degree perineal laceration reports feeling increased pain and pressure in her vaginal area. Which intervention should the practical nurse (PN) implement?