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 C

Explanation

Choice A Reason: I am so relieved that my family can be with me when I die

This statement reflects an accurate understanding of hospice care. Hospice care often allows patients to be surrounded by their loved ones during their final days. It emphasizes comfort and support, ensuring that the patient is not alone.

Choice B Reason: I will have pain medicine available when I need it

This statement is also correct. One of the primary goals of hospice care is to manage pain and other symptoms to ensure the patient’s comfort. Pain management is a critical component of hospice care, and medications are readily available to address the patient’s needs.

Choice C Reason: In a few months, I will be strong enough to travel to my cabin and go fishing

This statement indicates a need for further education. Hospice care is typically provided to patients who have a life expectancy of six months or less and who are no longer seeking curative treatment. The focus is on comfort and quality of life rather than recovery or improvement in physical strength. The expectation of becoming strong enough to travel and engage in activities like fishing is unrealistic in the context of hospice care.

Choice D Reason: I will be able to be in my own bed and home until I die

This statement is accurate. Hospice care often allows patients to remain in their own homes, surrounded by familiar surroundings and loved ones. The goal is to provide a comfortable and supportive environment for the patient during their final days.

A. Assist the client to identify the triggering situation and choose a coping strategy. B. Send the client to the crisis intervention unit for 23 hours of observation. C. Restrain the client to prevent self-harm. D. Advise the client to take an anxiolytic to decrease their anxiety level.

Correct Answer is A

Explanation

Choice A Reason: Assist the client to identify the triggering situation and choose a coping strategy

This is the correct answer. Assisting the client to identify the triggering situation and choose a coping strategy is a therapeutic approach that empowers the client to understand and manage their emotions. This intervention helps the client develop skills to cope with distressing feelings and reduces the likelihood of self-harm. It is essential to address the underlying issues and provide support in a constructive manner.

Choice B Reason: Send the client to the crisis intervention unit for 23 hours of observation

While sending the client to a crisis intervention unit may be necessary in some cases, it is not the first step. Immediate therapeutic intervention to help the client understand and manage their emotions is crucial. Observation alone does not address the underlying issues or provide the client with coping mechanisms.

Choice C Reason: Restrain the client to prevent self-harm

Restraint should be a last resort and only used when there is an immediate risk of harm that cannot be managed through other means. It is important to first attempt less restrictive interventions that help the client manage their emotions and behaviors.

Choice D Reason: Advise the client to take an anxiolytic to decrease their anxiety level

While medication can be part of the treatment plan, it should not be the first intervention. Addressing the client’s immediate emotional needs and helping them develop coping strategies is crucial. Medication can be considered as part of a comprehensive treatment plan but should not replace therapeutic interventions.

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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 is caring for a client who has been placed on hospice care. Which statement by the client indicates a need for further education?

Correct Answer is C

Explanation

Edited TextA client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious. The client wants to cut their arms. The nurse should first:

Correct Answer is A

Explanation

A physician orders Lithium 1.2 grams/day in three divided doses PO for a client with bipolar disorder. The medication is supplied as 300 mg/5 mL. How much will the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a 22-year-old female client who has bulimia nervosa and frequently self-induces vomiting. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY)

A college student experienced a sexual assault when out on a date. After several weeks of crisis intervention therapy, which statement by the client would indicate to the nurse that the student is making progress?

During intake assessment, the nurse is most likely to hear a client with major depressive disorder say which of the following statements about depression? (Select All that Apply.)

A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:

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):

During intake assessment, the nurse is most likely to hear a client with major depressive disorder say which of the following statements about depression? (SELECT ALL THAT APPLY)

The nurse in the Emergency Department (ED) assesses a 17-year-old patient with blue-tinged lips, slowed respirations, and pinpoint pupils. The patient has no response to painful stimuli. Which of the following should be the nurse’s priority action?