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

Answer and Explanation

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.

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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.

A. Fluconazole (Diflucan) B. Ciprofloxacin (Cipro) C. Varenicline (Chantix) D. Potassium iodide (KI)

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding?

Correct Answer is C

Explanation

The community health nurse is making a list of needed supplies in the event of a bioterrorism attack. The nurse recognizes that community members exposed to anthrax will need access to which of the following medications?

Correct Answer is B

Explanation

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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?