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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale: Initiating an exercise program may be a helpful intervention, but the primary goal for this client following a drug overdose and romantic relationship issues is to return to the previous level of functioning.

Choice B rationale: Identifying positive personal traits is a positive goal but may not be the most immediate priority for this client.

Choice C rationale: Returning to the previous level of functioning is the primary goal for hospitalization. This goal involves restoring the client's ability to manage daily life and cope with stressors.

Choice D rationale: Describing what is needed in a romantic relationship is important, but the immediate focus is on the client's overall functioning and safety.

A. Speak calmly to the client stating assurance of safety. B. Attempt to distract to another focus or activity. C. Help the client to identify thoughts that may be triggers. D. Explore past behaviors that have provided relief.

Correct Answer is A

Explanation

Choice A rationale: Speaking calmly and assuring the client of safety is a therapeutic intervention for managing severe anxiety and panic. It helps provide a sense of reassurance and safety to the client during an acute anxious episode.

Choice B rationale: Attempting to distract the client can be helpful in some situations, but in severe anxiety, the focus should initially be on providing a sense of safety and addressing immediate distress.

Choice C rationale: Helping the client identify thoughts is more appropriate during less acute moments or in the context of cognitive-behavioral therapy. In severe anxiety, the immediate focus is on providing support and reassurance.

Choice D rationale: Exploring past behaviors may be part of a comprehensive assessment but is not the first priority during an acute episode of severe anxiety.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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