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 B
Explanation
Bathing a bedfast client with the bed in a high position poses a potential risk to the client's safety. Lowering the bed to a safe height is important to prevent falls and injuries during the bathing procedure. The PN should promptly intervene and instruct the UAP to lower the bed to an appropriate level before continuing with the bathing process.
A. While remaining in the room to supervise the UAP is important, it should be done after ensuring the client's safety by lowering the bed. If the bed is not lowered, the risk of injury remains, and the PN should take immediate action to address the safety concern.
C. Determining if the UAP would like assistance is a valid consideration, but it should be secondary to addressing the safety issue of the bed height. Once the bed is lowered, the PN can assess if additional assistance is required and provide support accordingly.
D. Assuming care of the client immediately may be necessary if the client is in immediate danger or experiencing an urgent medical situation. However, in this case, the primary concern is addressing the safety issue related to the bed height, and the PN can address this by instructing the UAP to lower the bed.
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.
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