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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Observing how the UAP obtains temperatures will help the PN identify any errors or problems with the technique, equipment, or documentation. The PN can then provide feedback and guidance to the UAP to ensure accurate and reliable temperature measurements.
Correct Answer is D
Explanation
Hives (also known as urticaria) are raised, red, itchy welts on the skin that can be caused by an allergic reaction to medication, including antibiotics. It is essential for the PN to recognize this potentially severe allergic reaction and take immediate action.
Immediate action steps include:
- Stop the infusion of the intravenous antibiotic immediately.
- Notify the healthcare provider and report the allergic reaction.
- Assess the client's airway, breathing, and circulation to ensure there are no signs of respiratory distress or anaphylaxis.
- Administer prescribed emergency medications if needed (e.g., epinephrine, antihistamines).
- Monitor the client closely for any further signs of an allergic reaction or anaphylaxis.
The other assessment findings mentioned are also important to address, but they do not require immediate action:
A- Dry mouth with thirst: This may indicate dehydration, which should be addressed by encouraging the client to drink fluids, but it does not pose an immediate threat to the client's safety.
B- Warm skin with elastic turgor: This suggests that the client is adequately hydrated, and the skin's elasticity is normal, which is a positive finding.
C- Low-grade fever with diaphoresis: A low-grade fever indicates a mild elevation in temperature, and diaphoresis (sweating) may be the body's response to regulate temperature. The PN should monitor the client's temperature and assess for other signs of infection, but this finding does not require immediate action
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