A male client with paranoia has been admitted to the mental health unit, and upon arrival, he immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first?
Explain the unit rules to ensure his safety.
Gather required admission information.
Have the client put personal items away.
Sit and offer to listen to the client's concerns.
The Correct Answer is D
The first intervention the PN should implement is to **sit and offer to listen to the client's concerns**. It is important to approach the client in a calm and non-threatening manner and to establish a rapport with him. Offering to listen to his concerns can help the client feel heard and understood, and can help build trust between the client and the PN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Limited abduction of the legs in a newborn can be a sign of developmental dysplasia of the hip (DDH), a condition in which the hip joint is not properly formed. The practical nurse (PN) should notify the healthcare provider of this finding so that further assessment and appropriate intervention can be initiated.
Performing range of motion to the joint (A) is not appropriate without a healthcare provider's order. Continuing care as if this is a normal finding (B) is not appropriate because limited abduction of the legs in a newborn can be a sign of DDH. While documenting the finding in the record (D) is important, notifying the healthcare provider is the most important action for the PN to take next.
Correct Answer is C
Explanation
A positive indirect Coombs' test indicates that the mother has developed Rh antibodies against the baby's Rh-positive blood. This finding can result in hemolytic disease of the newborn, which is a condition in which the mother's Rh antibodies atack the baby's red blood cells, causing destruction and potential anemia.
The baby may require phototherapy for physiologic jaundice, but the Coombs' test result indicates a different issue.
The presence of an infectious blood-borne disease cannot be determined from this test.
The mother may still need Rho (D) immune globulin injections after delivery of an Rh-positive baby.
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