The nurse is caring for a client in the immediate postoperative period after an open cholecystectomy. Which task could be delegated to the unlicensed nursing assistant?

Listen to the breath sounds in all lung fields

Document the amount of output on the I & O sheet

Check the abdominal dressing for bleeding

Increase the IV fluid flow rate if the blood pressure is low

Answer and Explanation

The Correct Answer is B

a. Listen to the breath sounds in all lung fields: Assessing breath sounds is a more complex skill requiring a registered nurse's (RN) assessment.
b. Document the amount of output on the I & O sheet: Documenting intake and output (I&O) is a basic nursing task suitable for unlicensed nursing assistants (UNAs) under supervision.
c. Check the abdominal dressing for bleeding: Checking for bleeding requires a nurse's assessment due to the potential for complications.
d. Increase the IV fluid flow rate if the blood pressure is low: Adjusting IV fluids is a critical intervention requiring an RN's assessment and order.

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Correct Answer is C

Explanation

a. The unit can be managed with fewer staff. Seclusion requires close monitoring by staff.
b. Clients are encouraged to communicate with others. Seclusion is meant to be a temporary measure to prevent further harm, not necessarily to promote communication.
c. The reduced sensory input allows the client to regain control. Seclusion is a time-limited safety intervention used when a client poses a danger to themselves or others. It provides a safe space with reduced stimulation to allow the client to calm down and regain control.
d. Clients are forced to be responsible for themselves. Seclusion is not a punitive measure. The goal is to ensure safety and facilitate regaining control.

A. Excessive time spent discussing psychosocial stressors B. Disproportionate and persistent thoughts about the seriousness of one's symptoms C. Amnestic episodes in which the client is pain free D. Lack of physical symptoms

Correct Answer is B

Explanation

a. Excessive time spent discussing psychosocial stressors: Somatic Symptom Disorder focuses on physical symptoms, not necessarily psychological factors.
b. Disproportionate and persistent thoughts about the seriousness of one's symptoms: This is a hallmark symptom of Somatic Symptom Disorder. The client is likely preoccupied with their health beyond what's medically warranted.
c. Amnestic episodes in which the client is pain free: Amnesia is not a characteristic symptom of Somatic Symptom Disorder.
d. Lack of physical symptoms: Somatic Symptom Disorder by definition involves physical symptoms, even if they are not medically explained.

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The nurse is caring for a client in the immediate postoperative period after an open cholecystectomy. Which task could be delegated to the unlicensed nursing assistant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A new nurse orientee asks why a client admitted to the psychiatric unit is placed in seclusion. The nurse precepting the new nurse explains that which of the following is a benefit of seclusion?

Correct Answer is C

Explanation

The nurse is working with a client diagnosed with Somatic Symptom Disorder. What predominant symptoms should the nurse expect to assess?

Correct Answer is B

Explanation

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