A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement?
Consult with the charge nurse about implementing suicide precautions.
Sit quietly in the client's room until the client is ready to verbalize his feelings.
Leave the room after offering to return to the client's room at a later time.
Notify a member of the client's family of the need to come to stay with the client.
The Correct Answer is C
The correct answer is choice C: Leave the room after offering to return to the client's room at a later time.
Choice A rationale:
Consulting with the charge nurse about implementing suicide precautions is not appropriate in this situation. The client has not expressed suicidal ideation or intent, and such an action could be invasive and distressing for the client.
Choice B rationale:
Sitting quietly in the client's room until the client is ready to verbalize his feelings might seem supportive, but it disregards the client's request for alone time. It's essential to respect the client's wishes and provide an opportunity for self-reflection and privacy.
Choice C rationale:
Leaving the room after offering to return to the client's room at a later time is the most appropriate action. The client has requested solitude, and respecting his autonomy is crucial in building trust and rapport.
Choice D rationale:
Notifying a member of the client's family of the need to come stay with the client is not necessary at this point. The client's desire for alone time does not indicate an immediate need for family support. The practical nurse should first respect the client's request and give him space to process the news. If the client later expresses a need for family support, appropriate actions can be taken accordingly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Consecutive evening serum glucose greater than 260 mg/dL.
Choice A rationale:
A consecutive evening serum glucose greater than 260 mg/dL indicates persistent hyperglycemia. Inadequate NPH insulin dosage may lead to consistently high blood glucose levels, which can result in various complications.
Choice B rationale:
The complaint of cold feet and numbness is not a specific indicator of inadequate insulin dosage. Neuropathy and circulation issues can occur with poorly controlled diabetes, but they are not solely indicative of inadequate insulin.
Choice C rationale:
Nausea in the morning, even with the ability to eat breakfast, does not necessarily point to inadequate insulin dosage. It could be due to various factors, including dietary choices or other medical conditions.
Choice D rationale:
The wound on the ankle that starts to drain and becomes painful is not a specific sign of inadequate insulin dosage. Poorly controlled diabetes can lead to delayed wound healing, but it does not necessarily indicate that the current insulin dosage is insufficient.
Correct Answer is A
Explanation
Circumoral cyanosis is a bluish discoloration around the mouth that indicates inadequate oxygenation. It is an abnormal finding in a full-term newborn and requires immediate assessment and intervention by the PN.
The other options are not correct because:
- A positive Babinski's reflex is a normal finding in newborns that indicates intact neurological function. It is elicited by stroking the sole of the foot and observing the fanning of the toes.
- A negative Ortolani's sign is a normal finding in newborns that indicates no hip dislocation or dysplasia. It is elicited by abducting the hips and feeling for any clicking or clunking sensation.
- A large sacral "stork bite" is a common benign birthmark that appears as a reddish patch on the lower back or nape of the neck. It usually fades within the first year of life and does not require any treatment.
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