The practical nurse (PN) identifies which client behaviors that can increase the client's risk for hypertension? (Select all that apply.)

Choice A reason:

Requesting that the man get up and leave disregards the client's autonomy and right to privacy. It can be seen as intrusive and disrespectful, potentially causing embarrassment and distress to the client. In a long-term care facility, residents have the right to engage in consensual relationships. By asking the man to leave, the nurse would be infringing on the client's personal rights and freedoms. This action could also damage the trust and rapport between the nurse and the client, making future interactions more difficult.

Choice B reason:

Reporting the incident to the family breaches the client's confidentiality and privacy. The client has the right to engage in consensual relationships without family interference unless there are concerns about safety or capacity. Involving the family in such personal matters without the client's consent can lead to unnecessary conflict and distress. It is important for healthcare providers to respect the client's autonomy and confidentiality, ensuring that their personal choices are honored and protected.

Choice C reason:

Exiting the room and quietly closing the door respects the client's privacy and autonomy. It acknowledges their right to intimate relationships and maintains their dignity. This action demonstrates respect for the client's personal space and choices, fostering a supportive and respectful environment. By quietly exiting, the nurse avoids causing embarrassment or discomfort, allowing the client to maintain their dignity and privacy. This approach aligns with ethical principles in healthcare, emphasizing respect for the client's autonomy and personal rights.

Choice D reason:

Asking when the nurse should return interrupts the client's private moment. It can be handled more discreetly by returning later without disturbing them. This action, while less intrusive than asking the man to leave, still fails to fully respect the client's privacy. By asking when to return, the nurse is drawing attention to the situation, which can cause embarrassment and discomfort. A more respectful approach would be to quietly exit and return at a later time, ensuring that the client's privacy is maintained.

Collecting fingerstick glucose levels is the most important intervention for the PN to implement for a client who is receiving TPN. TPN is a method of feeding that bypasses the gastrointestinal tract and provides all the nutritional needs of the body through a vein. TPN contains a high concentration of glucose, which can cause hyperglycemia or fluctuations in blood sugar levels. Therefore, it is essential to monitor the client's glucose levels frequently and adjust the infusion rate or insulin administration accordingly.