The practical nurse (PN) hears an older resident of a long-term care facility shouts at an unlicensed assistive personnel (UAP) who shouts back at the resident. Which is the first action the PN should take?
Tell the resident and the UAP that shouting is not permitted.
Enter the room and tell the UAP to leave the room immediately.
Tell both of them to lower their voices in consideration of other residents.
Report the incident and the UAP for further action by the nurse-manager.
The Correct Answer is B
A. Tell the resident and the UAP that shouting is not permitted: While setting behavioral limits is important, addressing both parties simultaneously does not stop the immediate verbal conflict or protect the resident from potential emotional harm.
B. Enter the room and tell the UAP to leave the room immediately: The priority is to protect the resident from verbal abuse and de-escalate the confrontation. Removing the UAP stops the conflict, ensures the resident’s emotional safety, and allows the PN to assess the resident’s condition and provide reassurance.
C. Tell both of them to lower their voices in consideration of other residents: Asking them to quiet down minimizes the impact on others but fails to address the abusive nature of the exchange. The situation requires immediate intervention to stop the staff’s inappropriate behavior.
D. Report the incident and the UAP for further action by the nurse-manager: Reporting is necessary and should occur after the immediate threat has been resolved. The PN should first stop the confrontation and protect the resident before following up with appropriate documentation and notification to the nurse-manager.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Encourage the use of incontinence briefs: While briefs provide protection and maintain hygiene, they do not promote bowel control or help the client regain continence. This intervention is supportive but does not actively address bowel training goals.
B. Insert a rectal tube at specified intervals: Rectal tubes are invasive and typically reserved for acute, severe cases of fecal retention or obstruction. Routine use for bowel training is inappropriate and can cause discomfort or complications.
C. Administer a glycerin suppository 15 minutes after meals: Suppositories can stimulate bowel movements, but timing is crucial. Administering immediately after meals may not coincide with the client’s natural gastrocolic reflex, reducing effectiveness and cooperation with the training regimen.
D. Assist to a bedside commode 30 minutes after meals: This intervention leverages the gastrocolic reflex, which naturally increases bowel motility after eating. Assisting the client to the commode at this time supports regular, predictable bowel movements and is a central strategy in establishing a bowel training program.
Correct Answer is B
Explanation
A. Assess the client for nerve pain or paralysis: Assessing for nerve pain or paralysis may be relevant in clients with neurological or musculoskeletal conditions, but immune thrombocytopenic purpura (ITP) primarily affects platelet levels, increasing bleeding risk rather than nerve dysfunction.
B. Ensure the client has minimal clutter in the room: Keeping the client’s room free from clutter is the most important preventive action, as it minimizes the risk of falls, bruises, or trauma that can lead to serious bleeding in ITP.
C. Monitor the client's blood cell laboratory values: Monitoring laboratory values such as platelet counts helps assess disease progression but does not actively prevent physical injury. Injury prevention in ITP focuses on minimizing trauma and fall risk rather than tracking lab results.
D. Evaluate client's neurological status after exercising: Evaluating neurological status after exercise is beneficial for detecting complications like intracranial bleeding, but it is a secondary measure that occurs after an event. The primary goal is to prevent injury.
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