The practical nurse (PN) is caring for a client with psychosis who demonstrates an inability to communicate effectively. Which method should the PN use to interact with the client?

Discourage group activities.

Engage in regular contact.

Touch the client when speaking.

Establish a no-harm contract.

Answer and Explanation

The Correct Answer is B

the practical nurse (PN) should engage in regular contact with the client who demonstrates an inability to communicate effectively. Regular contact helps establish a therapeutic relationship and provides opportunities for observation and assessment of the client's needs and behavior. It also helps the PN to build trust with the client over time.
The other options listed are not appropriate methods for interacting with a client with psychosis who has difficulty communicating effectively:
A. Discouraging group activities: Group activities can be beneficial for individuals with psychosis as they provide opportunities for social interaction, skill-building, and support. It is important to encourage participation in appropriate group activities that are tailored to the client's needs and abilities.
C. Touching the client when speaking: Touching the client without their consent may be perceived as invasive or threatening, especially for individuals with psychosis who may already have difficulties with sensory processing or boundaries. It is important to respect the client's personal space and communicate through verbal means, maintaining a respectful and
non-intrusive approach.
D. Establishing a no-harm contract: No-harm contracts are typically used in the context of suicidal or self-harming behaviors to promote safety and identify support systems. While safety is important, it is not directly related to the communication difficulties associated with psychosis. Instead, the focus should be on developing a therapeutic relationship and finding effective means of communication with the client.

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Correct Answer is D

Explanation

A thready pulse refers to a pulse that is weak and difficult to palpate. It may disappear or weaken with light pressure. This can be an indication of decreased peripheral perfusion or reduced blood volume. By documenting the finding as "Thready pulse volume," the nurse is accurately describing the quality of the pulse and its response to light pressure.

Incorrect:

A. Missing pulse: A missing pulse would mean that the pulse is not palpable at all, even without applying pressure.
B. Light pressure applied to pulse: This is not a description of the pulse quality, but rather a description of the action taken to assess the pulse.
C. Pulse skips beats: This would mean that the pulse is irregular, with beats being missed or added. In this case, the pulse disappears when light pressure is applied and returns when the pressure is removed, which describes a thready pulse volume.

A. Coﬀee ground secretions drainage via nasogastric tube. B. Nasogastric tube suctioning. C. Assessing pain management response. D. Ineﬀective pain management report:

Correct Answer is C

Explanation

This is the correct answer because it is the most important and relevant action that the PN should do for a postoperative patient with a PCA machine. A PCA machine is a computerized device that allows the patient to self-administer a preset dose of pain medication, usually an opioid, by pressing a buton. The PCA machine is attached to an intravenous (IV) line that delivers the medication directly into the bloodstream. The PCA machine can provide eﬀective and individualized pain relief for postoperative patients, as well as increase their sense of control and satisfaction¹².

The PN should assess the pain management response of the postoperative patient with a PCA machine by monitoring their pain level, vital signs, oxygen saturation, sedation level, and side effects. The PN should use a valid and reliable pain scale, such as the numeric rating scale (NRS) or the visual analog scale (VAS), to measure the patient's pain intensity and relief. The PN should also check the settings and functioning of the PCA machine, such as the dose, lockout interval, and limit. The PN should document and report the patient's pain management response and any problems or complications with the PCA machine to the health care provider.

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The practical nurse (PN) is caring for a client with psychosis who demonstrates an inability to communicate effectively. Which method should the PN use to interact with the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

Correct Answer is D

Explanation

Which action should the practical nurse (PNA) prioritize for postoperative patient with a PCA (Patient- Controlled Analgesia) machine?

Correct Answer is C

Explanation

The practical nurse (PN) is assisting with the admission of a client with complications of left-sided heart failure. Which focused assessment should the PN implement first?

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