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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","E"]

Explanation

Choice A reason: Continuing with the triage process is not an immediate intervention that needs to be taken by the triage nurse because it can expose more people to the chemical spill and worsen their condition. The triage nurse should stop the triage process and alert the emergency department staff about the potential contamination.

Choice B reason: Evacuating the emergency department is an immediate intervention that needs to be taken by the triage nurse because it can prevent further exposure and harm to other clients, staff, and visitors. The emergency department should be cleared and sealed until it is safe to re-enter.

Choice C reason: Placing the client in a private room is not an immediate intervention that needs to be taken by the triage nurse because it can contaminate the room and its equipment, as well as pose a risk to anyone who enters or leaves the room. The client should be isolated in a designated area for decontamination.

Choice D reason: Treating the client after contaminated items are removed is not an immediate intervention that needs to be taken by the triage nurse because it can delay the treatment and increase the absorption of the chemical into the body. The client should be treated as soon as possible after decontamination.

Choice E reason: Sending the client and EMS crew to decontamination is an immediate intervention that needs to be taken by the triage nurse because it can remove or neutralize the chemical from their skin, clothing, and equipment, as well as reduce their symptoms and complications. The client and EMS crew should be directed to a designated area for decontamination.

A. Administer an antipyretiC. B. Decrease environmental stimulI. C. Assess the cranial nerves. D. Complete a vascular assessment.

Correct Answer is C

Explanation

Choice A reason: Administering an antipyretic is not the next action that the nurse should initiate because it does not address the priority problem of potential brain damage or death caused by meningococcal meningitis, which is a bacterial infection of the meninges that can rapidly progress to septic shock or disseminated intravascular coagulation.

Choice B reason: Decreasing environmental stimuli is not the next action that the nurse should initiate because it does not address the priority problem of potential brain damage or death caused by meningococcal meningitis, which can impair the function of the central nervous system and cause increased intracranial pressure, seizures, coma, or cranial nerve palsies.

Choice C reason: Assessing the cranial nerves is the next action that the nurse should initiate because it can provide vital information about the extent and severity of brain involvement caused by meningococcal meningitis, which can affect any or all of the 12 pairs of cranial nerves that control sensory and motor functions of the head and neck.

Choice D reason: Completing a vascular assessment is not the next action that the nurse should initiate because it does not address the priority problem of potential brain damage or death caused by meningococcal meningitis, which can cause inflammation and damage of blood vessels in various parts of the body, leading to ischemia, necrosis, or gangrenE.

View Question and Answer

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

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

An emergency room nurse is performing secondary triage on clients transported from the scene of a chemical spill. After caring for the clients, the EMS workers complain of nausea and dizziness. Which immediate interventions need to be taken by the triage nurse? SELECT ALL THAT APPLY

Correct Answer is ["B","E"]

Explanation

Correct Answer is C

Explanation

A nurse is delegating tasks to the assistive personnel (AP). The nurse should direct the AP to complete which of the following tasks first?

A nurse wishes to develop cultural competence when caring for clients. Which of the following actions should the nurse take first?

An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?

Discharge plans are being made for a 25-year-old hospitalized client diagnosed with multiple sclerosis. The client has significant muscle weakness in the lower extremities bilaterally. Which of the following facilities should the nurse expect this client to be discharged to?

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?

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?

The nurse is developing an activity plan for a client. The nurse should recognize that which activity plan would best conserve the client's energy without compromising physical or mental health?

A client is receiving rehabilitation for paralysis following a spinal cord injury and is diagnosed with reflex incontinencE. Which of the following isthe highest priority intervention the nurse should include in the plan of care?

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?