When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?

Leave the room and close the door quietly.

Ignore the behavior and hang the IV antibiotic.

Complete an unusual occurrence report.

Tell the client to stop the inappropriate behavior.

Answer and Explanation

The Correct Answer is A

A.   Leave the room and close the door quietly. Respecting the client's privacy is essential. The nurse should leave the room quietly and return later to administer the medication.
B.   Ignore the behavior and hang the IV antibiotic. Ignoring the behavior and proceeding with the medication administration would violate the client's privacy.
C.   Complete an unusual occurrence report. This situation does not require an incident report; it is a private matter between the client and the visitor.
D.   Tell the client to stop the inappropriate behavior. The behavior is not necessarily inappropriate within the context of the client's rights to privacy and intimacy.

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Correct Answer is ["A","B","C","D","E"]

Explanation

- A) Knowing the medications the patient takes is crucial for understanding her medical history and any potential interactions with treatments that may be administered.

- B) Understanding the events leading up to the fall can help in assessing the cause and potential injuries sustained, which is important for her current and future treatment plans.

- C) Information about the last meal is important for anesthesia considerations, in case surgery is required, and for understanding the patient's nutritional status.
- D) Knowing if the patient is pregnant is vital as it influences the management of her care and the urgency of certain tests, as well as the avoidance of potential harm to the fetus.
- E) Information about cohabitants can be useful for social support and may also provide additional information about the circumstances leading to the injury.
- F) While insurance status is a practical consideration, it is not clinically relevant to the secondary survey and immediate care of the patient. Therefore, it is not an appropriate question at this stage.

A. A Repeated requests for attention from the nurse. B. B Periodic sighing and shaking the head. C. C Argumentativeness and use of profanity. D. D Decreased activity level and change in affect.

Correct Answer is C

Explanation

A. While repeated requests for attention from the nurse might indicate distress, they are not necessarily indicative of potential aggression or disruptive behavior.
B. Periodic sighing and shaking the head could suggest the client's emotional state, but they are not as indicative of potential aggression or disruptive behavior as argumentativeness and profanity.
C. Monitoring for argumentativeness and the use of profanity is crucial as they can escalate into disruptive or potentially aggressive behavior. It's important to assess the client's agitation level and ensure the safety of both the client and others on the mental health unit.

D. Decreased activity level and a change in affect may suggest a worsening of the client's mental state but are not immediate concerns in terms of safety on the unit.

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When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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