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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Hydrochlorothiazide is a diuretic and may contribute to electrolyte imbalances, but it is not the most concerning medication in this situation. Choice B rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI), and the combination of an MAOI with certain foods or medications containing tyramine can lead
to a hypertensive crisis. The client's elevated blood pressure is of concern, and the nurse should notify the healthcare provider.
Choice C rationale: Losartan is an angiotensin II receptor blocker (ARB) used to treat hypertension. While it may contribute to blood pressure control, it is not the most concerning medication in this scenario.
Choice D rationale: Aspirin, at a dose of 81 milligrams, is often used for cardiovascular prophylaxis and is not the most concerning medication in this situation.
Correct Answer is D
Explanation
Choice A rationale: Ignoring comments about the sister's lack of medical education may not address the client's feelings and concerns. It is essential to explore the client's emotions.
Choice B rationale: Acknowledging that the sister's comments are overwhelming is supportive but may not actively address the client's self-perception.
Choice C rationale: Asking if the client thinks she might be a hypochondriac could be interpreted as judgmental and may not promote an open discussion about the client's concerns.
Choice D rationale: Asking about what is troubling the client, besides her sister's comments, encourages the client to express her feelings and provides an opportunity for the nurse to understand the client's perspective and concerns.
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