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 B

Explanation

In this scenario, the sudden regurgitation and cyanosis in a 24-hour-old infant indicate a potential airway obstruction or compromise. The immediate priority is to clear the airway and ensure adequate ventilation.

Suctioning the oral and nasal passages helps remove any potential obstruction or mucus that may be causing the cyanosis. This intervention aims to restore normal airﬂow and prevent further respiratory distress in the infant.

Let's brieﬂy evaluate the other options:

a) Turn the infant onto the right side.

Positioning the infant onto the right side does not directly address the potential airway obstruction or cyanosis. While positioning may have some benefit in certain situations, such as facilitating drainage, it is not the most appropriate immediate intervention in this case.

c) Give oxygen by positive pressure.

Administering oxygen by positive pressure may be necessary if the infant's oxygen saturation remains low after suctioning and clearing the airway. However, suctioning should be the initial intervention to address any potential airway obstruction or mucus before considering oxygen administration.

d) Stimulate the infant to cry.

Stimulating the infant to cry is not the appropriate intervention in this case. It does not directly address the potential airway obstruction or cyanosis. Crying requires a patent airway, and if the infant is already cyanotic, it suggests an obstruction or inadequate ventilation. Therefore, suctioning and clearing the airway take precedence over stimulating the infant to cry.

In summary, when a full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic, the practical nurse should immediately suction the oral and nasal passages to clear any potential airway obstruction or mucus. This intervention aims to restore normal airﬂow and ensure adequate ventilation for the infant.

A. Analgesics B. Antihistamines C. Antibiotics D. Anticonvulsants

Correct Answer is D

Explanation

Choice A reason: Analgesics are not the most effective classification of medications for treating this pain because they are drugs that relieve pain by blocking pain signals or reducing inflammation, but they do not address the underlying cause of trigeminal neuralgia, which is compression or irritation of the trigeminal nervE.

Choice B reason: Antihistamines are not the most effective classification of medications for treating this pain because they are drugs that block histamine receptors and reduce allergic reactions, but they do not affect the function or activity of the trigeminal nervE.

Choice C reason: Antibiotics are not the most effective classification of medications for treating this pain because they are drugs that kill or inhibit bacteria and treat infections, but they do not treat trigeminal neuralgia unless it is caused by a bacterial infection, which is rarE.

Choice D reason: Anticonvulsants are the most effective classification of medications for treating this pain because they are drugs that stabilize nerve membranes and reduce nerve impulses, which can decrease the frequency and intensity of trigeminal neuralgia attacks

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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?

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Naxlex Comprehensive Predictor Exams

A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the practical nurse (PN) implement?

Correct Answer is B

Explanation

A client diagnosed with trigeminal neuralgia experiencing intermittent, sudden, severe pain on the left side of the facE. The nurse identifies which classification of medications is most effective in treating this pain?

Correct Answer is D

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?