The nurse continues to care for the client.

Exhibits

For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.

Rationale:

A. You should not delegate this task because it requires nursing judgment: Weighing clients is a routine, non-invasive task that does not involve clinical decision-making. It does not require nursing judgment and is appropriate for delegation if the AP is competent.

B. You can delegate this task to an AP for new clients before performing a nursing assessment: Initial assessments must be performed by a licensed nurse. Weighing can be part of the assessment, but the nurse should first evaluate the client to determine whether delegation is appropriate.

C. You can delegate this task if the AP has been trained to use our scales: Delegation depends on the AP’s competence and familiarity with facility equipment. If trained, the AP can safely and accurately weigh clients, freeing the nurse for tasks requiring professional judgment.

D. You should not delegate this task because you have the capability to obtain clients weights: Delegation decisions should be based on scope of practice and task appropriateness, not whether the nurse is physically able to perform the task. Efficient delegation supports safe and effective care delivery.

Rationale:

A. Institutional policies and procedures: While helpful in guiding facility-specific protocols, policies do not override state regulations. An institution may allow tasks that exceed or fall short of legal scope, so this should not be the primary reference.

B. Written prescription from the provider: A provider’s order does not define or expand a nurse’s legal scope of practice. Even with a valid order, the nurse must independently verify whether they are legally permitted to carry out the task.

C. State Nurse Practice Act: The Nurse Practice Act (NPA) is the legal authority that defines what licensed nurses are permitted to do in their state. It is the most authoritative resource to determine whether a task is within the nurse’s legal scope of practice.

D. Verbal direction from the nurse manager: Even when given by a superior, verbal instructions must still comply with state law. A nurse manager’s guidance cannot authorize a task that lies outside the nurse’s legal scope.