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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
a. Assist the client to develop more effective coping mechanisms
c. Identify community resources for the client to use in a crisis
d. Educate the family about providing a safe and structured environment for the client
Explanation of Choices
Choice A Reason: Assist the Client to Develop More Effective Coping Mechanisms
Developing effective coping mechanisms is crucial for clients with a history of suicide attempts. Coping strategies help individuals manage stress, anxiety, and other emotional challenges that may trigger suicidal thoughts. Effective coping mechanisms can include mindfulness practices, cognitive-behavioral techniques, and stress management skills. By assisting the client in developing these skills, nurses can help reduce the risk of future suicide attempts and improve the client’s overall mental health.
Choice B Reason: Have a One-to-One Sitter for Outpatient Use
While having a one-to-one sitter can be beneficial in an inpatient setting to provide constant supervision and ensure safety, it is not typically feasible or necessary for outpatient care. Outpatient settings focus more on empowering the client with skills and resources to manage their condition independently. Continuous supervision in an outpatient setting may not be practical and could hinder the client’s sense of autonomy and self-efficacy.
Choice C Reason: Identify Community Resources for the Client to Use in a Crisis
Identifying community resources is a vital intervention for clients with a history of suicide attempts. Community resources can include crisis hotlines, support groups, mental health clinics, and emergency services. Providing the client with information about these resources ensures they have access to immediate help during a crisis. This support network can be crucial in preventing future suicide attempts and providing ongoing emotional and practical support.
Choice D Reason: Educate the Family About Providing a Safe and Structured Environment for the Client
Family education is essential in the care of clients with a history of suicide attempts. Educating the family about creating a safe and structured environment can help reduce triggers and stressors that may lead to suicidal thoughts. This education can include removing potential means of self-harm, establishing routines, and promoting open communication. A supportive family environment can significantly enhance the client’s recovery and reduce the risk of future suicide attempts.
Choice E Reason: Isolate the Client from All Stressful Situations That May Precipitate a Suicide Attempt
Isolating the client from all stressful situations is not a practical or effective intervention. While it is important to minimize exposure to significant stressors, complete isolation is neither feasible nor beneficial. Instead, the focus should be on helping the client develop resilience and coping strategies to manage stress. Learning to navigate and cope with stress is a critical part of recovery and long-term mental health management.

Correct Answer is A
Explanation
a. Tell me more about what unpleasant effects you have been experiencing
Explanation of Choices
Choice A Reason: Tell Me More About What Unpleasant Effects You Have Been Experiencing
This response is the most appropriate because it opens a dialogue between the nurse, the client, and the parent. Understanding the specific side effects the client is experiencing allows the nurse to gather detailed information, which is crucial for assessing the situation accurately. This approach shows empathy and concern for the client’s well-being and can help identify whether the side effects are manageable or if an alternative treatment plan is needed. It also ensures that the client feels heard and supported.
Choice B Reason: Stop Taking the Medication Immediately
Advising the client to stop taking the medication immediately is not appropriate without a thorough assessment and consultation with the prescribing physician. Abruptly discontinuing ADHD medication can lead to withdrawal symptoms and a resurgence of ADHD symptoms, which can negatively impact the client’s daily functioning and overall health. Medication changes should always be made under medical supervision to ensure safety and effectiveness.
Choice C Reason: I’ll Get the Physician to Discuss This Situation
While involving the physician is an important step, this response alone does not address the immediate concerns of the client and parent. It is essential for the nurse to first understand the specific issues before referring to the physician. This ensures that the physician has all the necessary information to make an informed decision about the client’s treatment plan. Additionally, this response may come across as dismissive if not coupled with an initial assessment by the nurse.
Choice D Reason: It’s Important to Take the Medication as Prescribed
While it is true that taking medication as prescribed is important, this response does not acknowledge the client’s and parent’s concerns about side effects. It may come across as dismissive and could damage the trust between the client, parent, and healthcare provider. Addressing the side effects and exploring possible solutions or alternatives is crucial for maintaining adherence to the treatment plan and ensuring the client’s well-being.
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