An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings.

The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take?

Request that the man get up and leave

Report the incident to the family

Exit the room and quietly close the door

Ask when the nurse should return

Answer and Explanation

The Correct Answer is D

The correct answer and explanation is:

d) Ask when the nurse should return. Correct

This is the action that the PN should take when entering the client's room and finding the couple in bed together. Asking when the nurse should return respects the client's privacy, dignity, and autonomy, while also ensuring that the client receives the necessary care.

The PN should acknowledge that the client has the right to express her sexuality and intimacy, as long as it is consensual and safe . The PN should also avoid making any judgments or assumptions about the client's relationship or preferences.

a) Request that the man get up and leave.

This is not the action that the PN should take when entering the client's room and finding the couple in bed together. Requesting that the man get up and leave is rude, disrespectful, and intrusive, as it violates the client's privacy, dignity, and autonomy. The PN should not interfere with the client's sexual or intimate activities, unless there is a clear indication of abuse, coercion, or harm.

b) Report the incident to the family.

This is not the action that the PN should take when entering the client's room and finding the couple in bed together. Reporting the incident to the family is inappropriate and unethical, as it breaches the client's confidentiality and autonomy. The PN should not share any information about the client's sexual or intimate activities with anyone without her consent, unless there is a clear indication of abuse, coercion, or harm.

c) Exit the room and quietly close the door.

This is not the action that the PN should take when entering the client's room and finding the couple in bed together. Exiting the room and quietly closing the door is passive and neglectful, as it ignores the client's needs and care.

The PN should not avoid or delay providing care to the client because of her sexual or intimate activities, unless she requests so . The PN should also communicate with the client and her partner in a respectful and professional manner.

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Correct Answer is C

Explanation

When a client reports experiencing numbness and ngling in the extremies, it is crucial for the praccal nurse (PN) to prioritise reporting the client's electrolyte levels to the healthcare provider. Electrolytes are essential minerals that help maintain the balance of fluids in the body and enable proper nerve and muscle function. Imbalances in electrolyte levels can lead to neurological symptoms, including numbness and ngling.

Opons a, b, and d are not the correct priories to report in this situation:

a) Hematocrit: Hematocrit measures the proportion of red blood cells in the blood. While abnormalies in hematocrit can indicate certain conditions, such as anaemia, it is not directly associated with numbness and ngling in the extremes.

b) Albumin and protein levels: Albumin and protein levels are important for assessing nutritional status and liver function. While low levels of protein can contribute to various health issues, they are not the primary concern when a client experiences numbness and ngling in the extremities.

d) White blood cell count (WBC): WBC count is used to evaluate the immune system's response to infection or inflammation. While infections or inflammatory conditions can cause neurological symptoms, such as ngling, it is not the primary concern in this specific case of numbness and ngling.

Therefore, the most appropriate laboratory value to prioritise reporting in this scenario is the client's electrolyte levels, as imbalances can directly contribute to the reported symptoms and may require prompt intervention.

A. Continue with the triage process. B. Evacuate the emergency department C. Place the client in a private room D. Treat the client after contaminated items are removed E. Send the client and EMS crew to decontamination

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

Explanation

Choice A reason: Continuing with the triage process is not an immediate intervention that needs to be taken by the triage nurse because it can expose more people to the chemical spill and worsen their condition. The triage nurse should stop the triage process and alert the emergency department staff about the potential contamination.

Choice B reason: Evacuating the emergency department is an immediate intervention that needs to be taken by the triage nurse because it can prevent further exposure and harm to other clients, staff, and visitors. The emergency department should be cleared and sealed until it is safe to re-enter.

Choice C reason: Placing the client in a private room is not an immediate intervention that needs to be taken by the triage nurse because it can contaminate the room and its equipment, as well as pose a risk to anyone who enters or leaves the room. The client should be isolated in a designated area for decontamination.

Choice D reason: Treating the client after contaminated items are removed is not an immediate intervention that needs to be taken by the triage nurse because it can delay the treatment and increase the absorption of the chemical into the body. The client should be treated as soon as possible after decontamination.

Choice E reason: Sending the client and EMS crew to decontamination is an immediate intervention that needs to be taken by the triage nurse because it can remove or neutralize the chemical from their skin, clothing, and equipment, as well as reduce their symptoms and complications. The client and EMS crew should be directed to a designated area for decontamination.

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An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports experiencing numbness and ngling in the extremies. Which of the client's serum laboratory values should the praccal nurse (PN) priorize reporng to the healthcare provider?

Correct Answer is C

Explanation

An emergency room nurse is performing secondary triage on clients transported from the scene of a chemical spill. After caring for the clients, the EMS workers complain of nausea and dizziness. Which immediate interventions need to be taken by the triage nurse? SELECT ALL THAT APPLY

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

Explanation

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An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings.

The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take?