Which information should the practical nurse (PN) collect during admission assessment of a terminally ill client to an acute care facility?

Name of funeral home to contact.

Contact information for client's next of kin.

Health care proxy documentation

Client's wishes regarding organ donation.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Health care proxy documentation.

Choice A rationale:

The name of the funeral home to contact is not immediately relevant during the admission assessment of a terminally ill client. This information can be collected later as part of end-of-life planning but is not critical for the initial assessment.

Choice B rationale:

While the contact information for the client’s next of kin is important for communication and support, it is not as crucial as health care proxy documentation for making immediate healthcare decisions.

Choice C rationale:

Health care proxy documentation is essential because it designates someone to make healthcare decisions on behalf of the client if they become unable to do so themselves. This ensures that the client’s healthcare preferences and decisions are respected and followed by the healthcare team.

Choice D rationale:

The client’s wishes regarding organ donation are important but are often included in the health care proxy documentation. This information is not as immediately critical as the health care proxy documentation during the admission assessment.

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Correct Answer is A

Explanation

The injury description by the mother varies from the child's version.

Choice A rationale:

The practical nurse (PN) should note the significant indicator of possible child abuse, which is the discrepancy between the mother's description of the injury and the child's version. In cases of child abuse, perpetrators often provide inconsistent or conflicting explanations about how the injuries occurred, raising suspicion of maltreatment. This inconsistency can be a red flag for the PN to further assess the situation and, if necessary, report concerns to the appropriate authorities.

Choice B rationale:

While the child looking at the floor when answering questions might be a behavior worth noting, it alone is not a definitive indicator of child abuse. Children may exhibit various emotional responses for various reasons, and it requires further assessment to determine if there are signs of abuse.

Choice C rationale:

The healing of abrasions on the child's arms, legs, and chest does not necessarily indicate child abuse. Children are active and prone to minor injuries, which are a normal part of growing up. The PN should investigate further to determine the cause of the injuries.

Choice D rationale:

The mother describing in detail what she did for her injured child does not automatically suggest child abuse. It is essential for the PN to gather more information and conduct a comprehensive assessment before drawing any conclusions.

A. Have the client sit down in the hall. B. Assist the client back to the room. C. Administer sublingual nitroglycerin. D. Obtain a 12-lead electrocardiogram.

Correct Answer is A

Explanation

The correct answer is choice A: Have the client sit down in the hall.

Choice A rationale: The PN should first have the client sit down to help alleviate the client's chest tightness and shortness of breath. Sitting down allows for better lung expansion and reduces the risk of falling due to dizziness or lightheadedness. This is the most appropriate initial action in response to the client's complaint.

Choice B rationale: While assisting the client back to their room is important, the PN should first ensure that the client is sitting down to help manage their symptoms. After the client is seated and more stable, the PN can then assist them back to their room for further assessment and intervention.

Choice C rationale: Administering sublingual nitroglycerin may be appropriate if the client is experiencing cardiac-related chest pain. However, the PN should first have the client sit down and gather more information about their symptoms before administering any medications.

Choice D rationale: Obtaining a 12-lead electrocardiogram can help assess the client's cardiac status, but it is not the first action that the PN should take in this situation. Ensuring the client's safety and managing their symptoms are immediate priorities. The PN can consider obtaining an electrocardiogram after addressing the client's immediate needs and assessing their condition further.

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Which information should the practical nurse (PN) collect during admission assessment of a terminally ill client to an acute care facility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment should the practical nurse (PN) note as the most significant indicator of possible child abuse?

Correct Answer is A

Explanation

While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the practical nurse (PN) implement first?

Correct Answer is A

Explanation

When caring for a child with sickle cell disease, the practical nurse (PN) expects that the child will most likely describe which symptom when experiencing a sickle cell crisis?

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A client is scheduled to receive a sublingual tablet and has difficulty swallowing tablets. Which is the best nursing action?

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.).

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