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 C
Explanation
Choice A reason: Delivering a clean voided urine specimen to the laboratory is not the first task that the AP should complete because it is not urgent or time-sensitivE. The specimen can be stored in a refrigerator or on ice until it is delivereD.
Choice B reason: Feeding a client who has bilateral casts due to upper arm fractures is not the first task that the AP should complete because it is not critical or life-threateninG. The client can wait until after breakfast to receive assistance with feedinG.
Choice C reason: Performing blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast is the first task that the AP should complete because it is essential and priority. The client needs to have their blood glucose level checked before receiving insulin to prevent hypoglycemia or hyperglycemiA.
Choice D reason: Obtaining an extra box of tissues for a client who is concerned about running out of them is not the first task that the AP should complete because it is not important or necessary. The client can use other alternatives such as paper towels or napkins until they get more tissues.
Correct Answer is C
Explanation
Accommodation refers to the ability of the eyes to adjust and focus on objects at different distances. When a client's pupils constrict as they change focus from a far object to a near object, it indicates that their pupils are reacting appropriately to accommodate the change in focus.
To document this finding accurately, the practical nurse (PN) should document "Pupils reactive to accommodation." This statement captures the observation that the pupils are constricting in response to the client changing their focus from a far object to a near object. It indicates normal pupillary response and accommodation.
Let's briefly evaluate the other options:
a) Consensual pupillary constriction present.
Consensual pupillary constriction refers to the simultaneous constriction of both pupils when light is shone into one eye. This finding is not directly related to accommodation or the client's change in focus.
Therefore, it is not the appropriate documentation for the given scenario.
b) Nystagmus present with pupillary focus.
Nystagmus refers to involuntary eye movements that can affect the alignment and focus of the eyes. The presence of nystagmus is not mentioned in the scenario, and it is not directly related to the client's change in focus. Therefore, it is not the appropriate documentation for the given scenario.
d) Peripheral vision intact.
Peripheral vision refers to the ability to see objects outside the central visual field. While important for assessing visual function, it is not directly relevant to the observed pupillary response during accommodation. Therefore, it is not the appropriate documentation for the given scenario.
In summary, when a client's pupils constrict as they change focus from a far object to a near object, the practical nurse should document "Pupils reactive to accommodation" to accurately describe the observed pupillary response during the accommodation process.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.