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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Correct Answer is C

Explanation

A. "We will help get you through this. You'll be fine.": While this statement may be meant to comfort, it dismisses the client's feelings and doesn't address the possibility of immediate harm or crisis. It’s important to validate the client’s emotions and assess for safety.

B. "What have you done to change your situation?": This response can come across as accusatory or judgmental, which may not be helpful in a crisis situation. It’s important to be supportive and nonjudgmental rather than questioning the client’s actions.

C. "Are you thinking about harming yourself?": The client's statement indicates feelings of hopelessness, which could signal suicidal ideation. Directly asking about self-harm or suicide helps assess the client's safety and provides an opportunity to intervene if necessary.

D. "You should remove yourself from this situation now.": While suggesting safety is important, this statement may feel too directive or overwhelming. The nurse should assess the client’s readiness for action and help them explore their options in a supportive way.

A. Provide positive reinforcement when the child uses eye contact. B. Administer haloperidol to the child as prescribed. C. Administer tranquilizing medications if the child becomes frustrated. D. Instruct the child's guardian on the use of implosion therapy.

Correct Answer is A

Explanation

A. Provide positive reinforcement when the child uses eye contact: Positive reinforcement is an effective strategy for children with autism, especially for improving communication behaviors like eye contact. It encourages social interaction in a non-overwhelming way.
B. Administer haloperidol to the child as prescribed: Haloperidol is an antipsychotic used for certain symptoms in ASD, but its use should be carefully monitored. Medication is not the first line for addressing communication challenges in children with ASD.
C. Administer tranquilizing medications if the child becomes frustrated: Using tranquilizing medications as a first response is inappropriate. Non-pharmacological approaches, like behavior modification, should be prioritized to manage frustration and other symptoms.
D. Instruct the child's guardian on the use of implosion therapy: Implosion therapy, which involves exposing the child to anxiety-provoking situations, is not appropriate for children with ASD. It can increase distress and is not suitable for managing the child's needs.

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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?

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