The practical nurse (PN) observes a client with the diagnosis of schizophrenia sitting all alone and talking quietly. Which action should the PN take?
Administer a PRN dose of haloperidol.
Ask the client if he is currently hearing voices.
Record the event but do not disturb the client.
Have the unlicensed assistive personnel (UAP) escort the client down to his room.
The Correct Answer is B
A. Administer PRN haloperidol: Medication not indicated without assessing cause.
B. Ask the client if he is currently hearing voices: Direct but nonjudgmental assessment of possible hallucinations.
C. Record event but don’t disturb client: Misses opportunity to assess for safety.
D. Have UAP escort client to room: Disruptive and doesn’t assess symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use normal saline to rinse the client's mouth: Normal saline is safe, non-irritating, and helps maintain oral mucosa integrity.
B. Avoid contact with the roof of the mouth: Unnecessary; oral care includes cleaning all oral surfaces gently.
C. Lower the head of the bed to 30 degrees: This increases aspiration risk; the head should be elevated or the client positioned side-lying.
D. Don sterile gloves prior to performing oral care: Clean gloves are sufficient; sterile gloves are not required.
Correct Answer is D
Explanation
A. Administer sublingual nitroglycerin: Not appropriate without confirming cardiac ischemia and provider order.
B. Assist the client back to the room: Delays immediate safety measures; sitting down is faster.
C. Obtain a 12-lead electrocardiogram: Important but comes after ensuring client safety and reducing workload on the heart.
D. Have the client sit down in the hall: First action is to stop activity and reduce oxygen demand while further assessment and interventions are arranged.
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