A nurse is teaching a newly licensed nurse about advance directives.
Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Choice A rationale

Asking about the content of the voices helps the nurse assess for command hallucinations, which can pose a safety risk to the client or others. This open-ended question encourages the client to elaborate, providing crucial information about the severity, nature, and potential danger of the auditory stimuli, which is the primary goal of the assessment.

Choice B rationale

This question is counterproductive because it asks for a causal explanation that the client, due to their altered neurochemical state, cannot provide. It can also be perceived as challenging the reality of the client's experience, which invalidates their feelings and can damage the therapeutic relationship. This is not a therapeutic approach.

Choice C rationale

This redirects the conversation away from the client's immediate distress and the core issue of their hallucinations. While therapy is part of treatment, it may not be appropriate at this moment of crisis. The nurse’s priority is to first assess the immediate risk and support the client's immediate needs, before introducing another activity.

Choice D rationale

Asking about medication adherence can be perceived as accusatory and may cause the client to become defensive. While medication non-adherence can contribute to symptom exacerbation, the immediate priority is to assess the current risk level posed by the hallucinations, not to lecture the client about medication. This question is not therapeutic.

Choice A rationale

Obtaining a client's vital signs is a routine, non-invasive procedure that can be safely delegated to an assistive personnel (AP). The AP is trained to measure and record objective data such as temperature, pulse, respiration, and blood pressure. The nurse is responsible for interpreting the data and assessing for any abnormal findings, but the data collection itself falls within the scope of practice for an AP. This allows the nurse to focus on more complex tasks.

Choice B rationale

Recording a client's intake after each meal is a task focused on data collection and falls within the scope of practice for an assistive personnel (AP). The AP can accurately measure and document the quantity of food and fluids consumed by the client. The nurse is then responsible for analyzing this data to monitor the client's nutritional status and fluid balance, and to identify any potential complications, such as dehydration or malnutrition. This is a routine, non-complex task.

Choice C rationale

Transferring a client is a routine activity of daily living that an assistive personnel (AP) is trained to perform. It involves moving a client safely from one location to another, such as from the bed to a chair or to physical therapy. The AP is taught proper body mechanics and client transfer techniques to prevent injury to both the client and themselves. The nurse would provide supervision and assess the client's mobility status before the transfer.

Choice D rationale

Inserting an NG tube is an invasive procedure that requires advanced knowledge of anatomy, physiology, and sterile technique. It carries a risk of complications, such as aspiration or incorrect tube placement. Therefore, this task is outside the scope of practice for an assistive personnel and must be performed by a licensed nurse or other qualified healthcare professional. The nurse is responsible for confirming tube placement and monitoring for adverse effects.

Choice E rationale

Instructing a client on the use of an incentive spirometer involves client education, which is a key component of the nursing process. The nurse must assess the client's learning needs, provide accurate and safe instructions, and evaluate the client's understanding and ability to perform the technique correctly. This cognitive and educational task requires the critical thinking skills of a licensed nurse and cannot be delegated to an assistive personnel. *.