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 A
Explanation
This is the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication he had to request three times. Asking the client to describe what happened shows empathy, respect, and active listening, and allows the PN to gather more information and validate the client's feelings and concerns. The PN should also apologize for the delay, assess the client's pain level and needs, and provide appropriate interventions and support.
Correct Answer is ["C","E","F"]
Explanation
C.Place pillows around the bed rails to provide padding: During a tonic-clonic seizure, the client may experience uncontrolled movements and convulsions. Placing pillows around the bed rails helps prevent injury by providing padding and cushioning.
E.Increase the supplemental oxygen to 10 L/min via nasal cannula: The client's oxygen saturation is dangerously low at 40%. Increasing the supplemental oxygen to 10 L/min via nasal cannula will help improve oxygenation and prevent hypoxia.
F.Manually ventilate the client with a bag-valve-mask: Since the respiratory rate is only 4 breaths/min, the client is not adequately ventilating on their own. Manual ventilation with a bag-valve maskwill provide necessary oxygenation and ventilation support during the seizure.
The other options are not appropriate actions at this time:
- Begin chest compressions: Chest compressions are indicated if the client's heart has stopped or if they are in cardiac arrest. Since the scenario describes a seizure, the client's heart is presumed to be functioning.
- Watch the seizure activity and document the time and client movement: Although documentation is important, during an active seizure, the priority is to ensure the client's safety and provide immediate interventions. Documentation can be done after the seizure has ended.
- Stop the IV fluids: There is no indication to stop the IV fluids based on the given information. IV fluids are generally continued unless there is a specific reason to discontinue them.
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