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 C
Explanation
Choice A rationale:
Reporting the incident to the family is not the first action the PN should take in this situation. It may be appropriate to inform the family later if necessary, but immediate action is needed to address the boundaries being crossed in the client's room.
Choice B rationale:
Requesting that the man get up and leave is not the first action the PN should take. This situation involves delicate and sensitive issues, and the PN should prioritize the client's privacy, dignity, and emotional well-being.
Choice C rationale:
The most appropriate first action is for the PN to exit the room and quietly close the door. This action respects the client's privacy and allows the couple to have some space and time to compose themselves.
Choice D rationale:
Asking when the nurse should return is not the first action to take. The PN needs to ensure the client's privacy and deal with the situation at hand discreetly. Later, the PN can discuss the incident with the client if necessary, or involve the appropriate authorities as per the facility's policy.
Correct Answer is C
Explanation
The correct answer is choice C. Suction the oral and nasal passages.
Choice A rationale:
Turning the infant onto the right side may not be the most appropriate intervention for cyanosis caused by regurgitation. Cyanosis signifies a lack of oxygen, and simply changing the infant's position might not address the underlying issue.
Choice B rationale:
Giving oxygen by positive pressure is not the immediate intervention needed for regurgitation-induced cyanosis. While administering oxygen is important, the first step should involve clearing the airway to ensure proper oxygenation.
Choice C rationale:
Suctioning the oral and nasal passages is crucial in this situation as the cyanosis is likely due to the infant's airway being obstructed by regurgitated material. Clearing the airway can restore normal breathing and oxygenation.
Choice D rationale:
Stimulating the infant to cry is not the appropriate action when cyanosis is present. Cyanosis indicates a serious problem with oxygenation, and crying may worsen the situation by further compromising the infant's breathing.
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