A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement?
Consult with the charge nurse about implementing suicide precautions.
Sit quietly in the client's room until the client is ready to verbalize his feelings.
Leave the room after offering to return to the client's room at a later time.
Notify a member of the client's family of the need to come to stay with the client.
The Correct Answer is C
The correct answer is choice C: Leave the room after offering to return to the client's room at a later time.
Choice A rationale:
Consulting with the charge nurse about implementing suicide precautions is not appropriate in this situation. The client has not expressed suicidal ideation or intent, and such an action could be invasive and distressing for the client.
Choice B rationale:
Sitting quietly in the client's room until the client is ready to verbalize his feelings might seem supportive, but it disregards the client's request for alone time. It's essential to respect the client's wishes and provide an opportunity for self-reflection and privacy.
Choice C rationale:
Leaving the room after offering to return to the client's room at a later time is the most appropriate action. The client has requested solitude, and respecting his autonomy is crucial in building trust and rapport.
Choice D rationale:
Notifying a member of the client's family of the need to come stay with the client is not necessary at this point. The client's desire for alone time does not indicate an immediate need for family support. The practical nurse should first respect the client's request and give him space to process the news. If the client later expresses a need for family support, appropriate actions can be taken accordingly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: Descriptions of numbness and tingling in fingers distal to the AVF.
Choice A rationale:
Descriptions of numbness and tingling in fingers distal to the arteriovenous fistula (AVF) suggest possible nerve compression or impaired blood flow, which are concerning findings. These symptoms could indicate reduced perfusion to the distal extremities and require immediate attention to prevent further complications.
Choice B rationale:
A loud and consistent bruit auscultated at the AVF site is an expected finding and indicates adequate blood flow through the fistula. A bruit is the sound of turbulent blood flow and is commonly heard over functional AV fistulas.
Choice C rationale:
Bruising at the AVF site is a common occurrence after the creation of the fistula. It is expected due to the surgical intervention and the manipulation of blood vessels. As long as the bruising is not severe or accompanied by other concerning symptoms, it does not need immediate reporting.
Choice D rationale:
The absence of the radial pulse distal to the AVF and the presence of the ulnar pulse are normal findings in a functioning AV fistula. The AV fistula diverts blood flow away from the radial artery, leading to a diminished pulse. This is not a cause for concern as long as the ulnar pulse is present, indicating adequate perfusion to the hand.
Correct Answer is B
Explanation
The correct answer is choice B: Thinning of the skin with loss of elasticity.
Choice A rationale:
While a decreased ability to communicate can be a significant challenge in elderly clients, it is not the primary physical characteristic of aging that contributes to the risk of pressure ulcers. Pressure ulcers develop due to prolonged pressure on specific areas of the skin, leading to reduced blood flow and tissue damage.
Choice B rationale:
Thinning of the skin with loss of elasticity is a critical physical characteristic of aging that contributes to the risk of pressure ulcers. As the skin becomes thinner and less elastic with age, it becomes more susceptible to injury from pressure and shear forces, increasing the likelihood of developing pressure ulcers.
Choice C rationale:
A 16 percent increase in overall body fat does not directly contribute to the risk of pressure ulcers. While changes in body composition occur with aging, the primary risk factors for pressure ulcers are related to skin integrity and mobility, not body fat percentage.
Choice D rationale:
Calcium loss in the bones (osteoporosis) is not the main contributing factor to pressure ulcers. Osteoporosis primarily affects bone density and strength but does not directly influence the development of pressure ulcers.
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