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
Choice A reason:
Administering the medication and alerting the charge nurse is not necessary in this scenario. The heart rate of 120 beats/minute is within the normal range for a 2-month-old infant, which is typically between 80 to 160 beats per minute. Therefore, there is no immediate concern that would require alerting the charge nurse.
Choice B reason:
Holding the medication and documenting the cardiac assessment would be appropriate if the heart rate were outside the normal range or if there were other signs of digoxin toxicity or adverse effects. Since the heart rate is within the normal range, this action is not warranted.
Choice C reason:
Administering the medication and documenting the heart rate is the correct action. The heart rate of 120 beats/minute falls within the normal range for a 2-month-old infant¹². Digoxin is prescribed to manage certain heart conditions, and as long as the heart rate is within the normal range and there are no signs of toxicity, the medication should be given as prescribed.
Choice D reason:
Holding the medication and rechecking the heart rate in 1 hour would be considered if the heart rate were borderline or if there were concerns about the stability of the infant's condition. Since the heart rate is stable and within the normal range, this action is unnecessary.
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.
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