A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. Which action should the practical nurse (PN) take to assist this client in diminishing his anxiety?

Teach him to limit sugar and caffeine intake.

Direct him to drink a glass of red wine at bedtime

Reinforce the reality of his financial situation.

Encourage him to initiate daily rituals

Answer and Explanation

The Correct Answer is A

A. Limiting sugar and caffeine intake can positively impact sleep and anxiety levels.
B. Drinking red wine at bedtime might initially induce sleep but could disrupt sleep patterns and worsen anxiety.
C. Reinforcing the reality of his financial situation might increase anxiety rather than diminish it.

D. Encouraging daily rituals might help establish a routine but might not directly address the anxiety related to financial stress.

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Correct Answer is A

Explanation

A. Ensuring minimal clutter reduces the risk of falls and injury due to potential bleeding episodes from ITP.
B. Monitoring blood cell laboratory values is important but doesn’t directly prevent physical injury.
C. Assessing for nerve pain or paralysis is essential for overall health but doesn't specifically prevent injury.
D. Evaluating neurological status after exercising is crucial but doesn't directly address the risk of physical injury associated with ITP.

A. Document the appearance of the wound as inflamed. B. Report the appearance of the dressing to the charge nurse. C. Compress the drainage device before closing the tab. D. Clamp the drainage tubing for the next four hours. E. Remove the drainage device and apply a pressure dressing

Correct Answer is ["B","C"]

Explanation

A. The wound is not inflamed, but rather discharging excessively. The PN should document the amount and color of the drainage, the size and location of the wound, and any signs of infection or complications.
B. The dressing needs to be changed as soon as possible to prevent infection and further blood loss. The charge nurse can also assess the need for additional interventions, such as suturing, hemostasis, or transfusion.
C. Compressing the device creates a vacuum that helps drain the fluid from the wound. The PN should squeeze the device until it is about half full, then close the tab securely.
D. Clamping the tubing can cause a backup of fluid in the wound, which can increase the risk of infection and impair healing. The PN should never clamp the tubing unless instructed by the provider.
E. Removing the device can cause more bleeding and disrupt the healing process. The PN should only remove the device when ordered by the provider or when it is no longer needed.

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A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. Which action should the practical nurse (PN) take to assist this client in diminishing his anxiety?

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Naxlex Comprehensive Predictor Exams

A female client with immune thrombocytopenic purpura (ITP) is transferred to a long-term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

Correct Answer is A

Explanation

The practical nurse (PN) observes a client's initial postoperative dressing and drain as seen in the picture. Which follow-up actions should the PN implement? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

The practical nurse (PN) is caring for a newborn whose mother has poorly controlled type 1 diabetes mellitus and observes the newborn is grunting with mild sternal retractions. The PN should recognize the newborn is exhibiting signs of which condition?

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The practical nurse (PN) observes a client's mouth and lips as seen in the picture. Which follow-up action is most important for the PN to take?

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