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 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.

A. Did the child perform a fingerstick? B. How much did the child exercise today? C. When did the child last urinate? D. Has the child eaten recently?

Correct Answer is A

Explanation

A. Checking the child’s blood glucose level via fingerstick is the most important step before administering insulin to prevent hypoglycemia or ensure the appropriate dose.
B. Exercise affects blood sugar, but the immediate priority is verifying the blood glucose level.
C. Urination patterns can indicate hyperglycemia, but they are not the most critical factor before insulin administration.
D. Eating is important, but insulin dosing should be based on blood glucose readings and meal intake combined.

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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 giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

Correct Answer is C

Explanation

Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the practical nurse (PN) to ask the child?

Correct Answer is A

Explanation

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