Psychiatric care technicians (PCTs) are unlicensed assistive personnel that are an integral part of the acute care mental healthcare team. Which of the following choices would be an example(s) of overdelegation by the nurse to a PCT? The nurse directs the PCT to (Select All that Apply):

Perform a neurological assessment on a patient in seclusion to compare the nurse’s findings.

Play cards with 3 patients during unstructured time.

Review follow-up care with a patient about to be discharged.

Set a goal for the day for a patient with a borderline personality disorder.

Obtain a weight on a patient with bipolar disorder in a hypomanic state.

Answer and Explanation

Correct Answer : A,C,D

Choice A Reason: Perform a neurological assessment on a patient in seclusion to compare the nurse’s findings

This task is an example of overdelegation. Performing a neurological assessment requires specialized knowledge and skills that are beyond the scope of practice for unlicensed assistive personnel. Such assessments should be conducted by a licensed nurse or healthcare provider to ensure accuracy and appropriate clinical judgment.

Choice B Reason: Play cards with 3 patients during unstructured time

This task is appropriate for a PCT. Engaging patients in recreational activities like playing cards does not require specialized clinical skills and falls within the scope of practice for unlicensed assistive personnel. It helps in providing social interaction and can be beneficial for the patients’ mental health.

Choice C Reason: Review follow-up care with a patient about to be discharged

This task is an example of overdelegation. Reviewing follow-up care involves providing important information about the patient’s ongoing treatment and care plan, which requires clinical knowledge and the ability to answer any questions the patient may have. This responsibility should be handled by a licensed nurse or healthcare provider.

Choice D Reason: Set a goal for the day for a patient with a borderline personality disorder

This task is also an example of overdelegation. Setting therapeutic goals for patients, especially those with complex mental health conditions like borderline personality disorder, requires clinical expertise and an understanding of the patient’s treatment plan. This should be done by a licensed nurse or mental health professional.

Choice E Reason: Obtain a weight on a patient with bipolar disorder in a hypomanic state

This task is appropriate for a PCT. Obtaining a patient’s weight is a routine task that does not require specialized clinical skills and falls within the scope of practice for unlicensed assistive personnel. It is a straightforward task that can be safely delegated.

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Correct Answer is A

Explanation

a. The CAGE Questionnaire

Explanation of Choices

Choice A Reason: The CAGE Questionnaire

The CAGE Questionnaire is a widely used screening tool for identifying potential alcohol use disorders. It consists of four questions that focus on key aspects of alcohol dependency: Cutting down, Annoyance by criticism, Guilty feelings, and Eye-openers (drinking first thing in the morning). This tool is quick to administer and has been validated in various clinical settings, making it an effective choice for initial screening of alcohol problems. The CAGE Questionnaire is particularly useful in preoperative assessments to identify patients who may be at risk for alcohol-related complications during and after surgery.

Choice B Reason: The Abnormal Involuntary Movement Scale

The Abnormal Involuntary Movement Scale (AIMS) is used to assess the severity of tardive dyskinesia and other involuntary movements, typically in patients taking antipsychotic medications. It is not designed to screen for alcohol use disorders. Therefore, it would not be appropriate for evaluating a client suspected of having a drinking problem.

Choice C Reason: The Clinical Institute Withdrawal Assessment Scale

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is a tool used to assess the severity of alcohol withdrawal symptoms. While it is valuable for managing patients already known to have alcohol dependence, it is not a primary screening tool for identifying alcohol use disorders. The CIWA-Ar is more appropriate for monitoring patients during detoxification rather than initial screening.

Choice D Reason: Refer the Client for Physician Evaluation

Referring the client for a physician evaluation is a reasonable step if the nurse suspects a drinking problem. However, using a validated screening tool like the CAGE Questionnaire can provide immediate, actionable information that can guide the next steps in care. The CAGE Questionnaire can help determine the severity of the problem and whether a referral to a specialist is necessary.

A. Strong negative feelings interfere with assessment and judgment. B. Awareness protects one’s own mental health. C. Positive feelings promote the development of sympathy for clients. D. Strong positive feelings lead to underinvolvement with the victim.

Correct Answer is A

Explanation

Choice A Reason:

Strong negative feelings interfere with assessment and judgment.

This statement is the most accurate explanation for why a nurse needs to be aware of their own feelings while working with a family experiencing domestic violence. Negative emotions such as anger, frustration, or sadness can cloud a nurse’s judgment and hinder their ability to objectively assess the situation. These feelings can lead to biased decision-making, which may compromise the quality of care provided to the victim. For instance, a nurse who feels anger towards the abuser might unconsciously project these feelings onto the victim, affecting their ability to offer unbiased support and intervention. Therefore, maintaining emotional awareness is crucial for ensuring accurate assessments and effective interventions.

Choice B Reason:

Awareness protects one’s own mental health.

While it is true that being aware of one’s feelings can help protect a nurse’s mental health, this statement does not directly address the impact of these feelings on the assessment and judgment process. Emotional awareness is important for self-care and preventing burnout, but the primary rationale for emotional awareness in the context of domestic violence is to ensure that the nurse can provide objective and effective care. Therefore, this choice is not as relevant to the specific question as choice A.

Choice C Reason:

Positive feelings promote the development of sympathy for clients.

Positive feelings such as empathy and compassion are important in nursing, but they can also lead to over-identification with the client, which may result in blurred professional boundaries. While sympathy can foster a supportive relationship, it is essential for nurses to maintain a balance between empathy and professional detachment to provide objective care. This statement does not fully capture the importance of emotional awareness in preventing negative feelings from interfering with assessment and judgment.

Choice D Reason:

Strong positive feelings lead to underinvolvement with the victim.

This statement is less accurate because strong positive feelings, such as empathy and compassion, are more likely to lead to over-involvement rather than underinvolvement. Over-involvement can result in blurred boundaries and difficulty maintaining professional objectivity. However, the primary concern in the context of domestic violence is the interference of negative feelings with assessment and judgment, making this choice less relevant to the question.

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Psychiatric care technicians (PCTs) are unlicensed assistive personnel that are an integral part of the acute care mental healthcare team. Which of the following choices would be an example(s) of overdelegation by the nurse to a PCT? The nurse directs the PCT to (Select All that Apply):

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Naxlex Comprehensive Predictor Exams

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. Which screening tool should the nurse use to further evaluate this possibility?

Correct Answer is A

Explanation

The rationale for the nurse needing to be aware of their own feelings while working with the family experiencing domestic violence is best explained as:

Correct Answer is A

Explanation

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