A nurse and assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Document the client's respiratory rate in 1 hr.

Monitor the client for an allergic reaction for 30 min.

Check the client's response to the medication in 1 hr.

Evaluate the client for therapeutic eﬀects in 30 min.

Answer and Explanation

The Correct Answer is A

After the nurse administers a PRN pain medication to a client, the nurse can assign the assistive personnel (AP) to document the client's respiratory rate in 1 hour. This is within the scope of practice of an AP.

The other tasks are not appropriate for an AP to perform.

Monitoring the client for an allergic reaction and evaluating the client for therapeutic eﬀects are both nursing assessments that should be performed by the nurse.

Checking the client's response to the medication is also a nursing assessment that should be performed by the nurse.

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Correct Answer is B

Explanation

The therapeutic relationship can be described in terms of four sequential phases: preinteraction phase, introduction/orientation phase, working phase, and termination phase . In the working phase, most of the therapeutic interventional activities are carried out . This is the phase where the nurse should help the client develop problem-solving skills.

The other options are not correct because:

a) The preinteraction phase starts when the nurse is given the responsibility to start a therapeutic relationship with a patient.

c) The introduction/orientation phase is the first meeting of the nurse with her client (patient).

d) The termination phase is the final stage of the nurse-client relationship.

A. Encourage the client to talk about current events. B. Give directions using simple phrases C. Orient the client to time and place twice per day D. Rotate assistive personnel to help the client with ADLs

Correct Answer is B

Explanation

b. Give directions using simple phrases.

The correct answer is b. Give directions using simple phrases.

Explanation:

When assisting with the plan of care for a client with Alzheimer's disease, it is important to consider their cognitive impairments and provide appropriate interventions. Giving directions using simple phrases is recommended because it helps the client beter understand and follow instructions. Complex or lengthy directions can be confusing and overwhelming for individuals with Alzheimer's disease. Using clear and concise language can enhance communication and facilitate the client's ability to engage in activities of daily living.

Explanation for the other options:

a. Encourage the client to talk about current events: While social interaction and engagement are beneficial for clients with Alzheimer's disease, their ability to comprehend and discuss current events may be limited due to cognitive impairments. It is important to adapt communication to the client's cognitive abilities and interests.

c. Orient the client to time and place twice per day: Frequent orientation to time and place can be helpful for clients with Alzheimer's disease, but the specific frequency should be based on the individual's needs and preferences. Some individuals may require more frequent orientation, while others may find it overwhelming. The plan of care should be individualized to address the client's specific needs.

d. Rotate assistive personnel to help the client with ADLs: Consistency and familiarity are important for individuals with Alzheimer's disease. Rotating assistive personnel frequently may disrupt the client's routine and cause increased confusion and agitation. Whenever possible, it is best to maintain a consistent caregiving team to provide familiarity and establish a therapeutic relationship with the client.

In summary, giving directions using simple phrases is an appropriate action when assisting with the plan of care for a client with Alzheimer's disease. This approach promotes eﬀective communication and enhances the client's ability to understand and follow instructions.

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A nurse and assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Nursing Test Bank

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