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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client's complaint of a leg cramp suggests the possibility of a muscle cramp or spasm, which is a common occurrence during labor. Extending the leg and flexing the foot helps stretch and relax the affected muscle, which can alleviate the cramp. This intervention helps relieve the muscle spasm and promotes increased blood circulation to the area, potentially reducing the intensity and duration of the cramp.
A. Elevating the leg above the heart is not necessary for relieving a leg cramp. It may be helpful in certain situations, such as in the case of venous insufficiency or swelling, but it is not the First-line intervention for a leg cramp.
B. Massaging the calf and foot can be beneficial in relieving a leg cramp. However, the initial action should be to extend the leg and flex the foot to actively stretch the affected muscle. If the cramp persists or if additional comfort measures are needed, then the PN may consider massaging the calf and foot.
D. Checking the pedal pulse in the affected leg is not directly related to relieving a leg cramp. It may be a relevant assessment in certain situations, such as suspected circulatory compromise or deep vein thrombosis, but it is not the primary intervention for a leg cramp.
Correct Answer is B, A, C, D
Explanation
The correct sequence for the interventions when caring for a client with a tracheostomy tube, after donning sterile gloves, is as follows:
Hyperoxygenate with a bag valve mask (BVM) using a nondominant hand. Insert sterile suction catheter in tracheostomy tube.
Activate suction by covering the catheter opening. Withdraw and rotate the catheter while suction is applied.
The first step is to hyperoxygenate the client using a bag valve mask (BVM) with the nondominant hand. This helps to ensure that the client receives adequate oxygenation during the suctioning procedure.
Next, the sterile suction catheter is inserted into the tracheostomy tube. The catheter is carefully advanced until resistance is met, ensuring it does not force its way in.
After the catheter is inserted, the suction is activated by covering the catheter opening. This creates negative pressure and allows for the removal of secretions.
Finally, the catheter is withdrawn and rotated while suction is applied. This helps to thoroughly suction the secretions from the tracheostomy tube.
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