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
Notify a member of the client's family of the need to come stay with the client
Leave the room after offering to return to the client's room at a later time
The Correct Answer is D
d) Leave the room after offering to return to the client's room at a later time.
This is the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Leaving the room after offering to return later respects the client's autonomy and privacy, while also showing empathy and availability. The client may need some time and space to process the diagnosis and cope with his emotions. The PN should not force the client to talk or stay with him if he does not want to, but should also not abandon him or ignore his needs.
a) Consult with the charge nurse about implementing suicide precautions.
This is not the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Consulting with the charge nurse about implementing suicide precautions is premature and unnecessary, as there is no evidence that the client is suicidal or at risk of harming himself. The client's request to be alone is a normal and understandable reaction to a stressful and life-changing situation, not a sign of suicidal ideation or intent.
b) Sit quietly in the client's room until the client is ready to verbalize his feelings.
This is not the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Sitting quietly in the client's room until he is ready to verbalize his feelings is intrusive and disrespectful, as it goes against the client's wishes and may make him feel uncomfortable or pressured. The PN should not impose their presence or expectations on the client, but should honor his request and give him some privacy.
c) Notify a member of the client's family of the need to come stay with the client.
This is not the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Notifying a member of the client's family of the need to come stay with him is inappropriate and unethical, as it violates the client's confidentiality and autonomy. The PN should not share the client's diagnosis or condition with anyone without his consent, nor should they assume that he wants or needs his family's support at this time. The PN should respect the client's right to decide who he wants to involve in his care and when.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
The client will have no signs of infection in the wound by day 7. Rationale: This outcome is appropriate because it sets a specific timeframe (day 7) for assessing the absence of infection in the wound. It provides a clear and measurable criterion for evaluating the effectiveness of the wound care plan.
Choice B rationale:
The client will report a pain level of 4/10 or less during dressing changes. Rationale: Pain management is an essential aspect of wound care. Setting a target pain level (4/10 or less) during dressing changes allows for monitoring and adjustment of pain management strategies, making it an appropriate outcome.
Choice C rationale:
The client will consume at least 75% of meals and snacks daily. Rationale: While nutrition is important for wound healing, this outcome is less directly related to the wound itself. Monitoring meal consumption is a valuable goal for overall health but may not be as closely tied to wound improvement as infection control, pain management, or wound care technique.
Choice D rationale:
The client will reposition self in bed every 2 hours with assistance. Rationale: Repositioning every 2 hours is an important preventive measure for pressure ulcer development. However, this choice may not be appropriate for this particular client if they are unable to reposition themselves, even with assistance. This outcome may not be achievable for all clients, and a more individualized goal may be necessary.
Choice E rationale:
The client will demonstrate proper wound care technique before discharge. Rationale: Ensuring that the client can perform proper wound care techniques independently or with minimal assistance is a crucial outcome. This ensures that the client can maintain wound hygiene and prevent complications after discharge.
Correct Answer is D
Explanation
The correct answer and explanation is:
d) Massage the fundus and avoid direct pressure on the cesarean incision.
This is the best action to take for a client who experiences a sudden gush of vaginal blood and clots after a
cesarean section. Massaging the fundus helps to stimulate uterine contractions and reduce bleeding.
Avoiding direct pressure on the incision prevents pain and wound dehiscence.
a) Insert an indwelling catheter to empty the bladder and contract the fundus.
This is not the first action to take for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Inserting an indwelling catheter requires a physician's order and may cause discomfort and infection. The client may already have a catheter in place after the surgery.
b) Check fundal consistency and continue to monitor the lochial flow amount.
This is not enough to do for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Checking fundal consistency and monitoring lochial flow are important, but they do not address the cause of bleeding or prevent further blood loss.
c) Return the client to bed and maintain bedrest until the lochial flow slows.
This is not appropriate for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Returning the client to bed and maintaining bedrest may delay ambulation and increase the risk of thromboembolism. It also does not stop the bleeding or treat the underlying cause.
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