A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistive personnel (AP). Which of the following responses should the nurse make?

"You can delegate this task if the AP has been trained to use our scales."

"You can delegate this task to an AP for new clients before performing a nursing assessment."

"You should not delegate this task because you have the capability to obtain clients' weights."

"You should not delegate this task because it requires nursing judgment."

Answer and Explanation

The Correct Answer is A

A. "You can delegate this task if the AP has been trained to use our scales.": Measuring and recording client weight is a noninvasive, routine task that does not require nursing judgment, making it appropriate to delegate to trained assistive personnel. The nurse remains responsible for ensuring accuracy and proper documentation.

B. "You can delegate this task to an AP for new clients before performing a nursing assessment.": Delegating weight measurement before a nursing assessment may result in incomplete or inaccurate data interpretation. Initial assessments require nursing judgment to identify baseline health status.

C. "You should not delegate this task because you have the capability to obtain clients' weights.": Possessing the ability to perform a task does not preclude delegation. The key consideration is whether the task requires professional judgment, which measuring weight does not.

D. "You should not delegate this task because it requires nursing judgment.": Obtaining a client’s weight is a standard, objective measurement and does not require clinical decision-making, so it does not meet the criteria for tasks that must be performed exclusively by a nurse.

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Correct Answer is D

Explanation

A. Resume tub baths and swimming after 24 hr: Clients should avoid tub baths, swimming, or submerging the incision for several weeks until the site has fully healed to prevent infection. Early immersion could compromise the surgical site.

B. Return in two weeks for a follow-up MRI: MRI scans are generally contraindicated or require special protocols for clients with an implantable cardioverter/defibrillator (ICD). Follow-up visits usually involve device interrogation, not routine MRI scheduling.

C. Expect to have a rapid pulse rate for the first few weeks: A rapid pulse is not an expected postoperative finding and may indicate arrhythmias or device malfunction. Clients should report palpitations or symptomatic tachycardia immediately.

D. Wear loose-fitting clothing: Loose-fitting clothing helps prevent irritation or pressure over the ICD incision site, promotes comfort, and reduces the risk of disrupting the device pocket during healing. This is an important part of postoperative care instructions.

A. Ritualistic behavior B. Preoccupied with aging C. Exhibits separation anxiety D. Suspicious of others

Correct Answer is B

Explanation

A. Ritualistic behavior: Ritualistic or repetitive behaviors are characteristic of obsessive-compulsive or obsessive-compulsive personality disorder, not narcissistic personality disorder. These behaviors reflect a need for control rather than grandiosity or self-centeredness.

B. Preoccupied with aging: Clients with narcissistic personality disorder often exhibit preoccupation with self-image, physical appearance, and how aging affects their attractiveness or status. Concerns about aging align with the disorder’s core features of vanity and self-importance.

C. Exhibits separation anxiety: Separation anxiety is typically observed in anxiety disorders, particularly in children, and is not a hallmark feature of narcissistic personality disorder, which centers on self-esteem regulation and interpersonal manipulation.

D. Suspicious of others: Suspiciousness is more characteristic of paranoid personality disorder. While narcissistic clients may be sensitive to criticism, pervasive distrust of others is not a defining trait of narcissistic personality disorder.

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A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistive personnel (AP). Which of the following responses should the nurse make?

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