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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The appropriate action for the practical nurse (PN) in this situation would be to ask the client if he is currently hearing voices. This step is important to assess the client's current state and gather information about his experiences. By directly asking the client about hearing voices, the PN can gain insight into the client's symptoms and determine if there is a need for further intervention or support.
B. Having the unlicensed assistive personnel (UAP) escort the client to his room may not be necessary at this point, as the client may simply be engaging in self-talk or may prefer some time alone. However, if the client's behavior becomes disruptive, agitated, or poses a safety risk, involving the UAP or taking other appropriate measures may be warranted.
C. Recording the event is important for documentation purposes, but it should not be the only action taken. It is crucial to actively assess the client's well-being and address any potential concerns or needs.
D. Administering an as-needed (PRN) dose of haloperidol without further assessment or consulting the healthcare provider would be inappropriate. Medication decisions should be based on a comprehensive evaluation of the client's symptoms and the healthcare provider's recommendations.
Correct Answer is A
Explanation
Taking a rectal temperature requires a higher level of skill and carries a higher risk of injury compared to other methods, especially when dealing with a 2-year-old child with leukemia. Given the client's condition, it is important to minimize any potential harm or discomfort. Taking a tympanic temperature is a safer alternative that provides an accurate reading without the risk of injury.
B. Reminding the UAP to lubricate the thermometer before insertion is not appropriate because the PN should not encourage or support the UAP in performing a rectal temperature on a high-risk client. The focus should be on using a safer and less invasive method.
C. Instructing the UAP to report the results to the PN immediately is not necessary in this situation because the PN has already determined that taking a rectal temperature is not appropriate.
Instead, the PN should guide the UAP toward using the tympanic method.
D. Observing the UAP to ensure the thermometer is inserted correctly is not appropriate in this case because the PN has already determined that taking a rectal temperature is not the recommended course of action. It is more appropriate to redirect the UAP to use an alternative method.
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