An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take?
Report the incident to the family.
Request that the man get up and leave.
Exit the room and quietly close the door.
Ask when the nurse should return.
The Correct Answer is C
Choice A rationale:
Reporting the incident to the family is not the first action the PN should take in this situation. It may be appropriate to inform the family later if necessary, but immediate action is needed to address the boundaries being crossed in the client's room.
Choice B rationale:
Requesting that the man get up and leave is not the first action the PN should take. This situation involves delicate and sensitive issues, and the PN should prioritize the client's privacy, dignity, and emotional well-being.
Choice C rationale:
The most appropriate first action is for the PN to exit the room and quietly close the door. This action respects the client's privacy and allows the couple to have some space and time to compose themselves.
Choice D rationale:
Asking when the nurse should return is not the first action to take. The PN needs to ensure the client's privacy and deal with the situation at hand discreetly. Later, the PN can discuss the incident with the client if necessary, or involve the appropriate authorities as per the facility's policy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the action that the PN should emphasize for the client to take before self-administration of the nasal spray because it clears the nasal passages of mucus and debris and allows for better absorption of the medication. The PN should also instruct the client to shake the botle well, tilt the head slightly forward, insert the nozzle into one nostril, close the other nostril with a finger, and press the pump while inhaling gently.
Correct Answer is D
Explanation
The correct answer is choiceD. Contact information for a women’s shelter.
Choice A rationale:
While providing a safety plan is important, it may not be the most immediate or practical resource for a client in an abusive situation. A safety plan is a detailed strategy for leaving an abusive relationship safely, but it requires time and preparation, which may not be feasible in an urgent situation.
Choice B rationale:
Paperwork for a restraining order is a legal step that can help protect the client, but it may not provide immediate safety. The process of obtaining a restraining order can take time, and the client may need immediate shelter and support.
Choice C rationale:
Documenting the report of abuse in the visit summary is important for medical and legal records, but it does not directly provide the client with immediate resources or safety. This documentation can be useful for future legal actions but does not address the client’s immediate need for safety and support.
Choice D rationale:
Providing contact information for a women’s shelter is the most appropriate response because it offers immediate safety and support. Women’s shelters provide a safe haven, counseling, legal support, and other resources necessary for individuals experiencing domestic violence.This option prioritizes the client’s immediate safety and well-being.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today