A nurse is planning to delegate client care for several clients in a mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

Witness an informed consent for a client who is scheduled for electroconvulsive therapy.

Explain the benefits of light therapy to a client who has depressive disorder.

Discuss the adverse effects of antianxiety medications with a client who has an anxiety disorder.

Participate in solitary activities with a client who has mania.

Answer and Explanation

The Correct Answer is D

Choice A reason: Witnessing an informed consent is a legal process that typically requires a licensed nurse or healthcare provider to ensure that the client fully understands the procedure and its risks. It is not appropriate to delegate this task to assistive personnel.

Choice B reason: Explaining the benefits of light therapy involves providing health education, which should be done by a licensed nurse or healthcare provider who has the necessary knowledge and training to ensure accurate information is conveyed.

Choice C reason: Discussing the adverse effects of medications is part of medication education and should be conducted by a licensed nurse or healthcare provider. Assistive personnel are not trained to provide this level of detailed medical information.

Choice D reason: Participating in solitary activities does not require clinical judgment and can be safely delegated to assistive personnel. This task involves engaging the client in activities that can help manage their mania and provide a therapeutic environment.

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Correct Answer is []

Explanation

Potential Condition:

a) Schizophrenia

Choice A reason: Schizophrenia is a chronic mental health condition characterized by symptoms such as delusions, hallucinations, disorganized speech, and significant social or occupational dysfunction. The client’s symptoms, including mumbling as if talking to unseen others and the belief that someone is trying to poison them, are indicative of psychotic features commonly associated with schizophrenia. The prescribed medications, clozapine and risperidone, are antipsychotics often used in the treatment of schizophrenia, further supporting this diagnosis.

Actions to Take:

d) Place the client in a room near the nurses’ station This action allows for close observation and quick intervention if the client’s condition worsens or if they exhibit behaviors that could be harmful to themselves or others.

f) Maintain the client taking their prescribed medications Continuing the prescribed antipsychotic medications is crucial for managing the symptoms of schizophrenia and preventing exacerbation of the condition.

Parameters to Monitor:

j) Command hallucinations Monitoring for command hallucinations is important as they can lead to dangerous behaviors, including harm to self or others, if the client acts on these hallucinations.

l) Suicidal ideation Patients with schizophrenia are at an increased risk for suicide, especially during acute episodes or when experiencing command hallucinations. Regular assessment for suicidal ideation is a critical component of care.

A. Instruct the client to expect ringing in the ears. B. Place the client in restraints for 1 hour. C. Initiate fall precautions for the client. D. Repeat the dose in 15 minutes if the client is still anxious.

Correct Answer is C

Explanation

Choice A reason: Ringing in the ears is not a common side effect of lorazepam. This medication is more likely to cause drowsiness or dizziness, which could increase the risk of falls.

Choice B reason: Restraints should only be used as a last resort when all other options have been exhausted and the client is a danger to themselves or others. Lorazepam is used to reduce anxiety, not to sedate to the point where restraints would be necessary.

Choice C reason: Initiating fall precautions is a prudent nursing action after administering lorazepam, especially if given intramuscularly, as the client may experience drowsiness or dizziness, increasing the risk of falls.

Choice D reason: Repeating the dose in 15 minutes is not recommended. The effects of lorazepam should be monitored, and additional doses should be administered based on the client's response and as prescribed by the healthcare provider.

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A nurse is planning to delegate client care for several clients in a mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is being treated for posttraumatic stress disorder (PTSD). The client states, "I'm not able to fall asleep easily or stay asleep." Which of the following recommendations should the nurse make?

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when supporting the client's refusal of medications?

A nurse is initiating a plan of care for a newly admitted client who has schizoid personality disorder. Which of the following interventions should the nurse include in the plan?

A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?

A nurse is assessing the sleep pattern of a client who has an anxiety disorder. The client reports having difficulty sleeping most nights. Which of the following recommendations should the nurse make?

A nurse is teaching the caregiver of a client who has advanced Alzheimer's disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching?