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A nurse is caring for a client in an emergency department (ED).

Exhibits
The nurse reviews the Nurses’ Notes from Day 1 at 1100.
Select 4 tasks the nurse should plan to delegate to the assistive personnel.

Perform daily weights.

Identify thoughts that reinforce disordered eating patterns.

Accompany the client to the restroom following meals.

Observe the client during meals.

Consult the dietitian to determine the client’s caloric intake.

Use cognitive behavioral techniques to address the client’s behavior.

Discuss measures to assist the client to develop a positive body image.

Encourage the client to discuss feelings of new eating patterns.

Check the client’s vital signs.

Answer and Explanation

Correct Answer : A,C,D,I

A. Perform daily weights: Daily weights are important to monitor progress and detect fluid or nutritional changes. This routine, non-invasive task is appropriate for delegation to assistive personnel (AP) under nurse supervision.

B. Identify thoughts that reinforce disordered eating patterns: Requires therapeutic communication and assessment, which are nursing responsibilities. Not appropriate for delegation to AP.

C. Accompany the client to the restroom following meals: Clients with bulimia are at risk of vomiting or purging after eating. Having an AP accompany the client helps prevent self-induced vomiting and ensures compliance with the treatment plan. The AP should report any unusual behavior to the nurse.

D. Observe the client during meals: Monitoring during meals ensures the client eats appropriately and avoids concealing or discarding food. This is a behavioral safety measure that can be delegated, while the nurse focuses on therapeutic interventions.

E. Consult the dietitian to determine the client’s caloric intake: Consulting other team members is a nursing role, involving coordination of interdisciplinary care.

F. Use cognitive behavioral techniques to address the client’s behavior: CBT and psychotherapy require specialized knowledge and are conducted by nurses or mental health professionals, not assistive personnel.

G. Discuss measures to assist the client to develop a positive body image: Involves therapeutic communication and counseling, not within the AP’s scope.

H. Encourage the client to discuss feelings of new eating patterns: Addressing emotions and behavioral change is a therapeutic intervention requiring nursing judgment.

I. Check the client’s vital signs: Vital signs provide data about orthostatic hypotension, dehydration, or arrhythmia risk. The AP can collect this data, while the nurse evaluates and interprets the results.

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Correct Answer is D

Explanation

Rationale:

A. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding, indicating that the hip joint is stable and not dislocated.

B. Symmetric gluteal and thigh skin folds: Symmetry suggests normal hip alignment and absence of hip dysplasia.

C. Equal leg length: Equal leg length is expected and indicates no hip dislocation.

D. Limited hip abduction: Limited abduction in a 1-month-old may indicate developmental dysplasia of the hip (DDH). In DDH, the femoral head does not fully seat in the acetabulum, restricting outward movement. Early diagnosis prevents long-term complications such as gait abnormalities or limb-length discrepancy.

A. Close the door to the client's room. B. Place the client in a semi-private room. C. Wear a lead apron when providing care. D. Limit visitors to 30 min per day. E. Instruct visitors who are pregnant to remain 3 feet from the client.

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

Explanation

Rationale:

A. Closing the door helps contain radiation and protect staff and visitors from exposure.

B. A semi-private room is contraindicated; the client must be in a private room to protect others from radiation exposure.

C. Wearing a lead apron during direct care reduces exposure to scatter radiation. The nurse should also avoid standing directly at the radiation source.

D. Limiting visitors to 30 minutes per day minimizes radiation exposure time. The principle of "time, distance, and shielding" guides radiation safety.

E. Pregnant visitors should not enter the client’s room at all, as fetal tissue is highly sensitive to radiation.

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A nurse is caring for a client in an emergency department (ED). Exhibits The nurse reviews the Nurses’ Notes from Day 1 at 1100. Select 4 tasks the nurse should plan to delegate to the assistive personnel.

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A nurse is caring for a client in an emergency department (ED).

Exhibits
The nurse reviews the Nurses’ Notes from Day 1 at 1100.
Select 4 tasks the nurse should plan to delegate to the assistive personnel.