A client with the diagnosis of schizophrenia sitting all alone and talking quietly. Which action should the PN take?
Ask the client if he is currently hearing voices.
Have the unlicensed assistive personnel (UAP) escort the client down to his room.
Record the event but do not disturb the client.
Administer an as-needed (PRN) dose of haloperidol.
The Correct Answer is A
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
In cases of suspected child abuse, inconsistencies or discrepancies between the child's account of the injury and the caregiver's version are concerning. It raises questions about the credibility of the explanation provided by the caregiver and suggests a possible attempt to conceal the true cause of the injury. Such discrepancies may indicate that the injury was intentionally inflicted or that the child is being coerced or influenced to provide a false account.
While the other assessment findings may raise some level of concern, they are not as significant as the discrepancy between the child's and mother's versions of the injury:
A. "The mother refuses to answer questions about family history." While this behavior may raise some suspicion or cause for further investigation, it alone does not conclusively indicate child abuse. It may be related to other factors such as privacy concerns or cultural differences.
B. "The child has several abrasions on the chest and legs." While the presence of abrasions can be concerning, they alone do not provide sufficient evidence of child abuse. Children are prone to injuries and can obtain abrasions during normal play and activities.
C. "The child looks at the floor when answering the nurse's questions." This behavior may suggest shyness, anxiety, or discomfort, but it is not a definitive indicator of child abuse. Some children may exhibit such behaviors due to their personality or other factors unrelated to abuse. It is important to consider the child's overall behavior and communication patterns in conjunction with other assessment findings.
Correct Answer is C
Explanation
Choice A reason:
Requesting that the man get up and leave disregards the client's autonomy and right to privacy. It can be seen as intrusive and disrespectful, potentially causing embarrassment and distress to the client. In a long-term care facility, residents have the right to engage in consensual relationships. By asking the man to leave, the nurse would be infringing on the client's personal rights and freedoms. This action could also damage the trust and rapport between the nurse and the client, making future interactions more difficult.
Choice B reason:
Reporting the incident to the family breaches the client's confidentiality and privacy. The client has the right to engage in consensual relationships without family interference unless there are concerns about safety or capacity. Involving the family in such personal matters without the client's consent can lead to unnecessary conflict and distress. It is important for healthcare providers to respect the client's autonomy and confidentiality, ensuring that their personal choices are honored and protected.
Choice C reason:
Exiting the room and quietly closing the door respects the client's privacy and autonomy. It acknowledges their right to intimate relationships and maintains their dignity. This action demonstrates respect for the client's personal space and choices, fostering a supportive and respectful environment. By quietly exiting, the nurse avoids causing embarrassment or discomfort, allowing the client to maintain their dignity and privacy. This approach aligns with ethical principles in healthcare, emphasizing respect for the client's autonomy and personal rights.
Choice D reason:
Asking when the nurse should return interrupts the client's private moment. It can be handled more discreetly by returning later without disturbing them. This action, while less intrusive than asking the man to leave, still fails to fully respect the client's privacy. By asking when to return, the nurse is drawing attention to the situation, which can cause embarrassment and discomfort. A more respectful approach would be to quietly exit and return at a later time, ensuring that the client's privacy is maintained.
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