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?
Request that the man get up and leave
Report the incident to the family
Exit the room and quietly close the door
Ask when the nurse should return
The Correct Answer is D
The correct answer and explanation is:
d) Ask when the nurse should return. Correct
This is the action that the PN should take when entering the client's room and finding the couple in bed together. Asking when the nurse should return respects the client's privacy, dignity, and autonomy, while also ensuring that the client receives the necessary care.
The PN should acknowledge that the client has the right to express her sexuality and intimacy, as long as it is consensual and safe . The PN should also avoid making any judgments or assumptions about the client's relationship or preferences.
a) Request that the man get up and leave.
This is not the action that the PN should take when entering the client's room and finding the couple in bed together. Requesting that the man get up and leave is rude, disrespectful, and intrusive, as it violates the client's privacy, dignity, and autonomy. The PN should not interfere with the client's sexual or intimate activities, unless there is a clear indication of abuse, coercion, or harm.
b) Report the incident to the family.
This is not the action that the PN should take when entering the client's room and finding the couple in bed together. Reporting the incident to the family is inappropriate and unethical, as it breaches the client's confidentiality and autonomy. The PN should not share any information about the client's sexual or intimate activities with anyone without her consent, unless there is a clear indication of abuse, coercion, or harm.
c) Exit the room and quietly close the door.
This is not the action that the PN should take when entering the client's room and finding the couple in bed together. Exiting the room and quietly closing the door is passive and neglectful, as it ignores the client's needs and care.
The PN should not avoid or delay providing care to the client because of her sexual or intimate activities, unless she requests so . The PN should also communicate with the client and her partner in a respectful and professional manner.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Fluconazole (Diflucan) is not a medication that community members exposed to anthrax will need access to because it is an antifungal drug that treats fungal infections, not bacterial infections. Anthrax is caused by Bacillus anthracis, a gram-positive spore-forming bacterium.
Choice B reason: Ciprofloxacin (Cipro) is a medication that community members exposed to anthrax will need access to because it is an antibiotic drug that treats bacterial infections, including anthrax. Ciprofloxacin is one of the recommended drugs for post-exposure prophylaxis and treatment of anthrax by the Centers for Disease Control and Prevention (CDC).
Choice C reason: Varenicline (Chantix) is not a medication that community members exposed to anthrax will need access to because it is a smoking cessation drug that helps people quit smoking, not treat infections. Varenicline has no effect on anthrax.
Choice D reason: Potassium iodide (KI) is not a medication that community members exposed to anthrax will need access to because it is a thyroid-blocking agent that protects against radioactive iodine exposure, not bacterial exposurE. Potassium iodide is used in case of nuclear accidents or attacks, not bioterrorism attacks involving anthrax.
Correct Answer is A
Explanation
Choice A reason: Monitoring vital signs and neurological status frequently is the priority intervention for the client because it can detect changes in the client's condition, such as increased intracranial pressure, bleeding, or infection, that require immediate action.
Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not the priority intervention for the client because it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumoniA. The client should be positioned with the head of the bed elevated at 30 degrees to reduce intracranial pressure and facilitate drainagE.
Choice C reason: Administering anticoagulant medications as prescribed is not the priority intervention for the client because it can worsen the bleeding and increase the risk of hemorrhagic transformation. Anticoagulants are contraindicated for clients who have hemorrhagic stroke, which is caused by rupture of a blood vessel in the brain.
Choice D reason: Assisting the client with active range of motion exercises is not the priority intervention for the client because it can cause fatigue, pain, or injury to the affected limbs. The client should be assisted with passive range of motion exercises to prevent contractures and maintain joint mobility.
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