A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first?
Explain the daily schedule of unit activities.
Review client rights of hospitalization.
Offer the client an as-needed (PRN) medication.
Describe the functions of the practical nurse (PN).
The Correct Answer is D
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Related Questions
Correct Answer is B
Explanation
the practical nurse (PN) should engage in regular contact with the client who demonstrates an inability to communicate effectively. Regular contact helps establish a therapeutic relationship and provides opportunities for observation and assessment of the client's needs and behavior. It also helps the PN to build trust with the client over time.
The other options listed are not appropriate methods for interacting with a client with psychosis who has difficulty communicating effectively:
A. Discouraging group activities: Group activities can be beneficial for individuals with psychosis as they provide opportunities for social interaction, skill-building, and support. It is important to encourage participation in appropriate group activities that are tailored to the client's needs and abilities.
C. Touching the client when speaking: Touching the client without their consent may be perceived as invasive or threatening, especially for individuals with psychosis who may already have difficulties with sensory processing or boundaries. It is important to respect the client's personal space and communicate through verbal means, maintaining a respectful and
non-intrusive approach.
D. Establishing a no-harm contract: No-harm contracts are typically used in the context of suicidal or self-harming behaviors to promote safety and identify support systems. While safety is important, it is not directly related to the communication difficulties associated with psychosis. Instead, the focus should be on developing a therapeutic relationship and finding effective means of communication with the client.
Correct Answer is ["B","E"]
Explanation
The PN should instruct the UAP to observe and report any ear drainage after removing the device, as this may indicate an infection or irritation of the ear canal. The PN should also instruct the UAP to verify that the device is labeled with client's identification, as this can prevent mix-ups or misplacement of the device. The PN should also instruct the UAP to remove ear wax from the device's surface, as this can improve the sound quality and prevent damage to the device.
The other options are not correct because:
a. Keeping the battery door closed during storage is not a correct instruction, as it can drain the battery and shorten its life span. The PN should instruct the UAP to keep the battery door open during storage, as this can conserve the battery power and prevent corrosion.
c. Storing the device on the window sill to prevent loss is not a correct instruction, as it can expose the device to heat, moisture, or sunlight, which can damage its components or affect its function. The PN should instruct the UAP to store the device in a dry, cool, and safe place, such as a case or a drawer.
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