The nurse reviews the Nurses' Notes from Day 1 at 1100.
Encourage the client to discuss feelings of new eating patterns.
Discuss measures to assist the client to develop a positive body image
Consult the dietitian to determine the client's caloric intake.
Identify thoughts that reinforce disordered eating patterns.
Observe the client during meals.
Accompany the dient to the restroom following meals.
Use cognitive behavioral techniques to address the client's behavior
Check the client's vital signs
Perform daily weights.
Correct Answer : E,F,H,I
Rationale:
A. Encourage the client to discuss feelings of new eating patterns: This requires therapeutic communication and assessment skills, which are beyond the scope of assistive personnel. Such discussions should be initiated and guided by the nurse or mental health professionals.
B. Discuss measures to assist the client to develop a positive body image: Promoting positive self-image involves complex therapeutic techniques and individualized planning, which must be performed by licensed staff, not delegated to assistive personnel.
C. Consult the dietitian to determine the client's caloric intake: Contacting other members of the healthcare team for clinical collaboration is the nurse’s responsibility. This involves interpretation of data and coordination of care, which cannot be delegated.
D. Identify thoughts that reinforce disordered eating patterns: Recognizing cognitive distortions requires clinical judgment and is a core part of therapeutic nursing or psychological care. It cannot be delegated to assistive personnel.
E. Observe the client during meals: Assistive personnel can monitor the client while eating to help prevent purging behaviors. Meal observation is a standard component of bulimia nervosa management and does not require clinical decision-making, making it appropriate for delegation.
F. Accompany the client to the restroom following meals: Clients with bulimia may attempt to purge after eating, so monitoring them post-meal is critical. This task involves supervision rather than evaluation and is suitable for assistive personnel under nursing guidance.
G. Use cognitive behavioral techniques to address the client's behavior: CBT strategies are specialized interventions requiring advanced training, typically carried out by licensed nurses, therapists, or psychologists. These are not within the role of assistive personnel.
H. Check the client’s vital signs: Vital signs collection is a routine task that falls within the scope of assistive personnel when the client is stable. The nurse remains responsible for interpreting any abnormalities.
I. Perform daily weights: Weighing the client is a routine, objective measurement that does not require nursing judgment. It is appropriate to delegate this task as long as the AP follows the nurse’s instructions on timing and procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Disconnecting the catheter from the drainage bag to empty the bag: This increases the risk of introducing pathogens into the closed urinary drainage system, leading to potential catheter-associated urinary tract infections (CAUTIs). The drainage bag should be emptied without breaking the system.
B. Emptying the drainage bag when it is half full: This prevents backflow of urine, which could lead to infection or increased bladder pressure. Regular emptying also allows for accurate measurement of urine output and maintains client comfort.
C. Keeping the drainage bag above waist level: Elevating the bag above the bladder increases the risk of backflow of urine into the bladder, which can introduce bacteria and cause infection. The bag should always remain below the level of the bladder.
D. Using sterile gloves when emptying the drainage bag: Sterile gloves are not necessary for this procedure. Clean gloves are sufficient since the nurse or AP is not entering the sterile parts of the urinary system but rather emptying the bag from the outlet port.
Correct Answer is C
Explanation
Rationale:
A. Encourage the client to attend a group therapy session: This action does not immediately address the restraint status. The client’s calm and cooperative behavior should prompt reassessment of restraint necessity before introducing other interventions.
B. Continue to monitor the client every 15 min: Ongoing monitoring is important but it is not the priority once the client has de-escalated. If the behavior no longer warrants restraints, the nurse should act promptly to remove them to preserve the client’s rights and dignity.
C. Remove the restraints from the client: Restraints should be discontinued as soon as the client demonstrates self-control and no longer poses a risk to themselves or others. Keeping restraints on unnecessarily can lead to psychological harm, reduced mobility, and legal/ethical violations.
D. Offer the client PRN pain medication: Offering pain medication assumes the client is experiencing discomfort, but there is no indication of pain in the scenario. Medication is not the priority when behavioral signs point to de-escalation and restraint removal is warranted.
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