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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The practical nurse (PN) should recognize that a newborn whose mother has poorly controlled type 1 diabetes mellitus and is exhibiting grunting with mild sternal retractions is exhibiting signs of patent ductus arteriosus. Patent ductus arteriosus is a condition in which the ductus arteriosus, a blood vessel that connects the pulmonary artery to the aorta, fails to close after birth. This can result in abnormal blood ﬂow between the aorta and pulmonary artery, leading to respiratory distress.

Hypothyroidism (Option A) and hyperinsulinemia (Option C) are conditions that can occur in newborns, but they do not typically present with grunting and sternal retractions.

Ventral septal defect (Option D) is a congenital heart defect that can cause respiratory distress, but it is not specifically associated with maternal diabetes.

A. Burp the infant after every 10 mL of formula and re-feed any volume that is spit up. B. Place the infant in the right lateral position to facilitate gastric emptying. C. Oﬀer a pacifier during the feedings to satiate the sucking reﬂex associated with feedings. D. Flush the GT with 50 mL water and clamp the GT to prevent leakage.

Correct Answer is C

Explanation

During gastrostomy (GT) feedings for a newborn infant with a tracheo-esophageal repair, the practical nurse (PN) should oﬀer a pacifier to satiate the sucking reﬂex associated with feedings. Sucking is a natural reﬂex for infants and providing a pacifier during feedings can help satisfy this need and promote comfort. The other interventions listed may also be important to implement during GT feedings, but oﬀering a pacifier to satiate the sucking reﬂex is the most appropriate intervention in this situation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

A newborn infant with a tracheoesophageal repair is receiving gastrostomy (GT) feedings postoperatively. Which intervention should the practical nurse (PN) implement during the GT feedings?

Correct Answer is C

Explanation

The practical nurse (PN) is assisting with the admission of a 12-month-old child with a history of frequent colds and growth failure. Testing is being planned for a possible diagnosis of cystic fibrosis (CF). Which information is most important for the PN to obtain?

A male college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The client tells the practical nurse (PN) that the voices are saying, "Kill, kill." Which question should the PN ask the client next?

Another person tells the practical nurse (PN) that her 7-year-old child frequently wets the bed at night. Which information should the PN provide?

A child with cerebral palsy (CP) is taking baclofen, a relaxant. Which assessment finding indicates to the practical nurse (PN) that the drug is eﬀective?

A primigravida who is at 10-weeks gestation is hospitalized on the antepartum unit for pyelonephritis. The client tells the practical nurse (PN) that she has had several episodes of nausea. When reviewing her lunch menu, which food should the PN discourage her from choosing?

A client who is multiparous at 36-weeks gestation is diagnosed with placenta previa. The practical nurse (PN) should monitor this client for which condition?

At a prenatal visit, a primigravida client confides to the practical nurse (PN) that her partner is abusive. Which information should the PN provide?

A 4-year-old girl is brought to the emergency room with a fractured arm. Which information should be a basis for the practical nurse (PN) to suspect child abuse?