A client with obsessive-compulsive disorder (OCD) reports, "Thoughts stick in my mind and the rituals I use are stupid, but I cannot control them. People laugh at me, but they do not understand how awful it is. I am a burden to my family because I cannot hold a job. I do not know how much longer I can live this way." Which information is most important for the practical nurse (PN) to ask in response to the client's statements?

Question about which rituals are most often used to reduce anxiety.

Ask if the obsessions and compulsions interfere with sleep.

Inquire if the distress could lead to considering suicide as an option.

Determine what makes the client think people are laughing.

Answer and Explanation

The Correct Answer is C

This is the most important information for the PN to ask because it assesses the client's risk for self-harm and suicidal ideation. The client's statements indicate hopelessness, low self-esteem, and impaired functioning, which are potential warning signs of suicide. The PN should ask the client directly about any thoughts or plans of harming themselves and provide support and safety measures as needed.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

This finding requires immediate action, as it indicates that the client is not receiving the prescribed amount of oxygen, which can compromise the oxygenation and perfusion of the tissues. The PN should adjust the ﬂowmeter to deliver 3 liters per minute of oxygen, and check for any leaks or kinks in the tubing.

The other options are not correct because:

B. The absence of a humidifier does not require immediate action, as it is not a critical component of the oxygen delivery system. A humidifier can help moisten the dry oxygen and prevent mucosal irritation, but it is not essential for oxygenation.

C. The supine position does not require immediate action, as it is not a contraindication for oxygen therapy. The client may prefer this position for comfort or rest, and it does not aﬀect the oxygen delivery or uptake.

D. The snug fit of the cannula does not require immediate action, as it is not a problem for oxygen therapy. The cannula should fit snugly against the client's cheeks to prevent dislodgment or slippage, and it does not interfere with the oxygen ﬂow or diﬀusion.

A. Instruct the UAP to report any abnormal findings. B. Remind the UAP to check the client's pulse volume. C. Demonstrate the correct pulse site to the UAP. D. Confirm the accuracy of the pulse rate obtained by the UAP.

Correct Answer is C

Explanation

- A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate.

- To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse.

- In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.

Therefore, option C is the correct answer, while options A, B, and D are incorrect.

Option A is incorrect because instructing the UAP to report any abnormal findings does not address the error in technique.

Option B is incorrect because reminding the UAP to check the pulse volume does not address the error in technique.

Option D is incorrect because confirming the accuracy of the pulse rate obtained by the UAP does not address the error in the technique.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action?

Correct Answer is A

Explanation

The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

Correct Answer is C

Explanation

An older adult female asks the practical nurse (PN) if she should get a Herpes zoster (shingles) vaccination because she gets cold sores on her mouth when she is sick or stressed. Which response should the PN provide?

While caring for a client with Guillain-Barre syndrome, which finding should the practical nurse (PN) report to the charge nurse?

Immediately after log-rolling a client to a lateral position, which intervention should the practical nurse (PN) implement?

Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

An older female adult who was admited to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

A client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge intravenous (IV) catheter with normal saline is infusing at a rate of 150 mL/hour. Which intervention should the nurse implement first?

Find patient data about a client below. After the nurse assesses the client, the physician writes orders. The nurse reviews the orders. Which 2 orders should the nurse complete first?