The nurse is completing an admission assessment for a client with a known history of depression and multiple, unexplained fractures. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?
Screen the client for domestic violence.
Determine the client's risk for suicide.
Ask client to state a chief complaint for admission.
Obtain a baseline set of vital signs.
The Correct Answer is D
Choice A rationale: Screening the client for domestic violence requires a more comprehensive assessment and interpretation of findings, which is beyond the scope of practice for the UAP.
Choice B rationale: Determining the client's risk for suicide involves complex judgment and should be assessed by a licensed healthcare provider, not a UAP.
Choice C rationale: Asking the client to state a chief complaint for admission involves initial communication and assessment skills, which should be performed by licensed nursing staff.
Choice D rationale: Obtaining a baseline set of vital signs is a routine task that can be delegated to the UAP. It is a non-complex and standard part of the admission process.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: "I know that bathing helps prevent infectious diseases" is a factual statement but may not necessarily reflect progress in the client's overall functioning and engagement in self-care. It focuses on the practical aspect of bathing rather than the client's motivation and insight.
Choice B rationale: "Others say I am dirty and smell badly, so I will bathe" suggests an external motivation rather than intrinsic motivation. Progress is better indicated when the client expresses a personal desire to engage in self-care activities.
Choice C rationale: "I will take a bath today as requested" indicates compliance with external requests rather than an internal desire to care for oneself. It is essential to foster the client's intrinsic motivation for self-care.
Choice D rationale: "I feel good when I take care of myself" reflects an internal motivation and positive reinforcement associated with self-care. This statementsuggests progress in the client's willingness to engage in personal hygiene activities.
Correct Answer is A
Explanation
Choice A rationale:A. The drug that was ingested is the most important information because knowing the specific substance determines the course of treatment. For example, acetaminophen overdose requires administration of N-acetylcysteine, while opioid overdose requires naloxone. Different drugs have different toxic effects, antidotes, and supportive measures, making this information critical to providing appropriate and potentially life-saving care.
Choice B rationale: The time since drug ingestion is important because many interventions, such as gastric lavage or activated charcoal, are time-sensitive. However, without knowing the specific drug, it is difficult to determine whether these interventions are necessary or effective
Choice C rationale: Knowing the reason for the suicide attempt is important for overall assessment and treatment planning but may not provide immediate information for the current situation.
Choice D rationale: Past history of depression is relevant to the client's overall mental health, but in the context of a suspected drug overdose, the time since ingestion takes precedence.
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