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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Checking the medical record for the correct signed consent form prior to the examination is the primary responsibility of the practical nurse (PN). Ensuring that the consent form is properly signed and documented in the medical record is crucial for legal and ethical reasons before proceeding with any invasive procedure.
B. While explaining the examination is important, obtaining informed consent is the responsibility of the provider, not the PN. The PN can clarify information but should not be the one to explain the procedure in detail and obtain the signature.
C. Explaining the procedure to a family member and obtaining their signature is not appropriate, as consent must come from the client unless they are incapacitated. Family members cannot give consent for procedures unless legally designated as such.
D. While asking if the client understands the exam and the need for the consent form is a good practice for ensuring informed consent, the PN's responsibility focuses more on verifying that the consent has been properly obtained and documented.

A. Encourage the client to resume normal activities after medication administration. B. Observe the client for involuntary movements of the lips and tongue every day. C. Perform a daily whisper test of the client's hearing to detect symptoms of ototoxicity. D. Implement ongoing assessments for signs of shallow or slow breathing.

Correct Answer is D

Explanation

Tramadol is an opioid analgesic that can depress the respiratory system and potentially cause respiratory depression. Therefore, it is crucial for the PN to closely monitor the client's breathing pattern, depth, and rate. Assessing for signs of shallow or slow breathing is important to detect any potential respiratory depression and take appropriate action promptly.
The other options listed are not directly related to the administration of tramadol:

A. Encouraging the client to resume normal activities after medication administration is not an appropriate intervention for a client experiencing torticollis. The focus should be on pain management, rest, and implementing measures to relieve the torticollis.
B. Observing the client for involuntary movements of the lips and tongue every day is not specifically related to tramadol. This intervention is more relevant to monitoring for tardive dyskinesia, a side effect associated with certain antipsychotic medications.
C. Performing a daily whisper test of the client's hearing to detect symptoms of ototoxicity is not necessary with tramadol. Ototoxicity refers to damage to the inner ear, often caused by specific medications, but tramadol is not known to cause ototoxic effects.

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A client with the diagnosis of schizophrenia sitting all alone and talking quietly. Which action should the PN take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

Correct Answer is A

Explanation

The practical nurse (PN) is assisting with the plan of care for a client who is experiencing torticollis from a traumatic injury sustained during a football game. The client received a prescription for tramadol. Which intervention should the PN include in the client's plan of care?

Correct Answer is D

Explanation

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