A charge nurse in an emergency department is assigning tasks. Which off the following tasks should the nurse delegate to an assistive personnel?

Transfer a client who has delirium from a bed to a wheelchair.

Inform a client who has schizophrenia about available community services.

Obtain a list of current medications from a client who is experiencing a manic episode.

Insert an NG tube for a client who has acetaminophen toxicity.

Answer and Explanation

The Correct Answer is A

A. Transfer a client who has delirium from a bed to a wheelchair: Assisting with transfers and mobility is within the scope of practice for an AP, especially if the client is stable and the task does not require clinical decision-making.

B. Inform a client who has schizophrenia about available community services: This task requires clinical judgment and communication skills to ensure that the client understands the information and that the services are appropriate for their needs. It should be performed by a nurse, not an AP.

C. Obtain a list of current medications from a client who is experiencing a manic episode: While obtaining a medication list is an important task, it requires assessment and evaluation of the client's condition, which should be done by a nurse, especially when the client is in a manic state and may have impaired judgment or communication.

D. Insert an NG tube for a client who has acetaminophen toxicity: Inserting an NG tube is an invasive procedure that requires clinical knowledge and skill. It should be performed by a licensed nurse or physician, not an AP.

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Free Nursing Study Resources

Correct Answer is ["C","E","H"]

Explanation

Rationale for correct choices:

Ask the client if they have been hit, slapped, or kicked within the past year: This question is specific and nonjudgmental, helping the client disclose abusive behaviors without feeling pressured. It's important for identifying signs of abuse that may not be immediately obvious.
Ask the client to clarify the circumstances of their injuries: Clarifying the circumstances of the injuries helps the nurse assess the situation and detect any discrepancies in the explanation that may suggest abuse. It can also guide the next steps in care and safety planning.
Discuss with the client the factors that precipitate violence: Identifying triggers and patterns of violence empowers the client to recognize and avoid dangerous situations, and to plan for their safety moving forward.

Rationale for incorrect choices:

Interview the client with another nurse present: The primary goal during is to establish a private and trusting environment where the client feels safe to disclose. The presence of another person can make a client feel less comfortable and less likely to speak openly about sensitive issues like intimate partner violence.
Ask questions in different ways until the client provides an answer: Repeating or rephrasing questions multiple times could make the client feel pressured or coerced, which may hinder trust and open communication. It’s important to respect their pace and comfort level.
Refrain from asking the client if they are afraid of their partner: Fear of the partner is a crucial indicator of abuse, and not asking about it may prevent the client from disclosing important information. Acknowledging fear helps assess the level of risk and urgency.
Assure the client that their medical team feels sympathy for their injuries and disapproval for the person responsible for inflicting them: While empathy is important, making value judgments about the abuser can undermine the client's trust, making them feel judged or unsupported in their decisions.
Inform the client that they should have fought back: Telling the client what they "should have done" may inadvertently place blame on them and discourage further disclosures. It’s vital to maintain a supportive, nonjudgmental stance to ensure the client feels safe.

A. Amnesia B. Nausea and vomiting C. Hyperthermia D. Tachycardia E. Respiratory depression F. Combativeness

Correct Answer is ["A","B","E"]

Explanation

Rationale for correct choices:

Amnesia: GHB is known to cause memory loss or amnesia, particularly retrograde amnesia, which makes the client unable to recall events that occurred during intoxication. This is a common effect of GHB when it is used as a "date rape drug."
Nausea and vomiting: GHB can cause gastrointestinal symptoms, including nausea and vomiting. This is a well-known side effect, especially when the drug is ingested in larger quantities or in combination with alcohol.
Respiratory depression: One of the most concerning effects of GHB is respiratory depression. This can be life-threatening, as GHB has a sedative effect on the central nervous system, potentially leading to slow or shallow breathing and, in extreme cases, respiratory failure.

Rationale for incorrect choices:

Hyperthermia: GHB typically causes sedation and hypothermia rather than hyperthermia. While stimulant drugs (e.g., methamphetamine) can lead to increased body temperature, GHB is more commonly associated with decreased body temperature.
Tachycardia: GHB does not typically cause tachycardia. It is more likely to cause bradycardia (slower heart rate) or maintain normal heart rates due to its sedative effects.
Combativeness: GHB is a sedative and CNS depressant, not a stimulant. Therefore, it is unlikely to cause combativeness, which is more typically associated with stimulant drugs like cocaine or methamphetamine.

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A charge nurse in an emergency department is assigning tasks. Which off the following tasks should the nurse delegate to an assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","E","H"]

Explanation

The nurse is continuing to care for the client in the emergency department (ED). Exhibits The nurse should monitor the client for which of the following based on the result of the client's laboratory test? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

A nurse is caring for a client who has a personality disorder. Which of the following statements made by the client indicate they are coping with the maladaptive defense mechanism of displacement?

A nurse is assessing a client who has post-traumatic stress disorder. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse in a mental health facility is caring for a newly admitted client. Which of the following resources should the nurse recommend to help the client adapt to the health care setting?

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply).

A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the client indicates an understanding of the teaching?

Based on the assessment findings, which of the following actions should the nurse take? Select all that apply.

A nurse is caring for a client who has alcohol use disorder. Which of the following statements made by the client indicates the client has a support system?

A nurse in an alcohol treatment facility is caring for a client who states, "My job is so stressful that the only way I can cope is to drink should recognize that the client is displaying which of the following defense mechanisms?