A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Respond to family members about a client's condition.

Determine which clients should be seen first.

Clean and dress client abdominal wounds.

Take vital signs on clients as they are admitted.

Answer and Explanation

The Correct Answer is D

Choice A reason: Responding to family requires clinical judgment and communication skills beyond AP scope. Nurses handle this in mass casualty for accuracy.

Choice B reason: Triage prioritization needs nursing assessment skills, not AP training. Determining care order is a licensed responsibility in emergencies like this.

Choice C reason: Cleaning and dressing wounds involves sterile technique and assessment, outside AP scope. Nurses perform this in mass casualty settings.

Choice D reason: Taking vital signs is within AP scope, providing data for nurse triage. It’s a routine task, safely assigned in a mass casualty event.

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Correct Answer is A

Explanation

Choice A reason: Monitoring post-meals prevents purging, a common anorexia behavior. One hour ensures food retention, supporting nutritional recovery and countering compensatory actions effectively.

Choice B reason: Weighing every 2 days tracks trends, but daily is standard in anorexia to monitor refeeding risks like edema or cardiac strain more closely.

Choice C reason: Vital signs twice weekly miss acute changes in anorexia, like bradycardia from malnutrition. Daily checks are needed for safety during early treatment.

Choice D reason: Two hours per meal allows purging opportunities in anorexia. Shorter, supervised times prevent this, ensuring intake for nutritional rehabilitation success.

A. Hypersomnia B. High cholesterol C. Urinary tract infection D. Amyloid plaque

Correct Answer is C

Explanation

Choice A reason: Hypersomnia causes excessive sleep, not delirium’s acute confusion. It’s unrelated to the restlessness and disorientation seen in this client’s presentation.

Choice B reason: High cholesterol affects vessels, not acute brain function. It’s a chronic risk, not a trigger for delirium’s sudden cognitive shift here.

Choice C reason: UTIs in older adults often cause delirium via systemic inflammation and toxins. This matches the client’s disorientation and restlessness as a risk.

Choice D reason: Amyloid plaque links to Alzheimer’s, a chronic condition. Delirium is acute; plaque doesn’t explain the sudden onset in this scenario.

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A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?

Correct Answer is C

Explanation

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