A young adult client, a parent with two small children, looks despondent and depressed after learning from the healthcare provider that the client has multiple sclerosis. Which nursing intervention should the practical nurse (PN) implement immediately after this client has been told of the diagnosis?

Tell the client to see the good parts of life with two children who love the client.

Provide the client with information about the Multiple Sclerosis Society.

Allow the client to be alone by providing privacy to grieve.

Sit quietly with the client and answer questions the client may ask.

Answer and Explanation

The Correct Answer is D

A. Telling the client to focus on the positive aspects of life might seem dismissive of the client's current emotional state and concerns.
B. Providing information about support groups is helpful but should follow an initial supportive and empathetic response.
C. Allowing the client privacy may be necessary later, but initially, it is important to offer support and presence.
D. Sitting quietly with the client and answering any questions demonstrates empathy, support, and availability, helping the client process the new diagnosis and feel less isolated.

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Correct Answer is D

Explanation

A. Palpating the brachial artery before inflating the blood pressure cuff is a correct technique to locate the artery and ensure accurate blood pressure measurement.
B. Counting respirations while palpating the radial pulse is a correct technique as it minimizes the risk of the client altering their breathing pattern.
C. Asking the client to relax their arm before taking the blood pressure is an appropriate step to ensure an accurate measurement.
D. Inserting a thermometer into the sublingual pocket after the client sips water can affect the accuracy of the temperature reading, as water can alter the temperature measurement.

A. Respiratory rate 18 breaths/minute B. Heart rate 101 beats/minute C. Capillary refill 2 seconds D. Breath sounds clear and equal bilaterally E. Turban dressing is saturated with serosanguinous drainage F. Blood pressure 140/84 mm Hg G. Temperature 101.9° F (38.8° C) H. Client is awake and alert

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

Explanation

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) obtain a client's vital signs. The PN should intervene when observing the UAP performing which technique?

Correct Answer is D

Explanation

Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

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

Explanation

Exhibits Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings. Which three of the following client findings indicate that the client may still have a fluid volume deficit?

A client with Parkinson's disease is experiencing decreased postural reflexes, rigidity, retropulsive gait, and shuffling. Which intervention is most important for the practical nurse (PN) to implement?

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

The practical nurse (PN) plans to use distraction techniques while a client undergoes a brief painful procedure. Which action should the PN implement during the procedure?

A client with a malabsorption syndrome has a low serum calcium level. The practical nurse should monitor the client for which problem?

The practical nurse (PN) is documenting the insertion of a urinary catheter for a female client with urinary retention. What information should the PN include during the electronic documentation of the procedure? Select all that apply.

The practical nurse (PN) is assisting a client to the bathroom after a right cataract extraction. The client has an eye shield over the right eye. How should the PN assist the client during ambulation?