A nurse is conducting several health assessments. Which action(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Completing a follow-up focused assessment

Assessing a client's mental health status

Obtaining a client's vital weight

Obtaining a client's vital signs

Assessing a client's medication history

Answer and Explanation

Correct Answer : C,D

A. Completing a follow-up focused assessment: Focused assessments require nursing judgment and clinical decision-making to identify changes in a client’s condition. This task cannot be delegated to UAP because it involves interpretation of findings and determining interventions.

B. Assessing a client's mental health status: Mental health assessments require specialized knowledge and critical thinking to evaluate mood, thought processes, and risk factors. UAPs do not have the training to perform these assessments safely or interpret the results.

C. Obtaining a client's vital weight: Measuring a client’s weight is a routine, noninvasive task that does not require nursing judgment. UAPs are trained to safely obtain and record vital weights, making this appropriate to delegate.

D. Obtaining a client's vital signs: Vital signs are standard, routine measurements that UAPs can reliably perform. Nurses can delegate this task while retaining responsibility for interpreting the results and making clinical decisions.

E. Assessing a client's medication history: Gathering medication history involves evaluating prescriptions, interactions, and adherence patterns. This requires nursing knowledge and critical thinking, so it should not be delegated to UAPs.

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Correct Answer is A

Explanation

A. Explain the parts of the assessment and ask permission to move forward: Providing a clear explanation of the assessment process and asking for consent demonstrates respect for the client’s cultural values and personal boundaries. This approach helps reduce anxiety, promotes trust, and ensures the client feels in control of their care.

B. Return at a later time to complete the physical assessment and interview: Delaying the assessment may not address the client’s immediate health needs and does not actively engage the client in reducing their apprehension. It may also prolong anxiety without providing reassurance.

C. Get a different nurse to complete the physical assessment and interview: While changing nurses might help in some cases, it does not directly address the client’s apprehension or foster communication and trust. The underlying need is for explanation and consent, not just a change in personnel.

D. Continue with the physical assessment so the client can get treatment: Proceeding without consent disregards the client’s autonomy and may increase anxiety or distrust. It could violate ethical principles and negatively impact the nurse–client relationship.

A. It reduces the client's anxiety during the assessment B. It helps identify areas of tenderness and abnormalities C. It is the only technique used for abdominal assessment D. It allows for the assessment of the abdominal organs

Correct Answer is B

Explanation

A. It reduces the client's anxiety during the assessment: While gentle touch may help the client feel more comfortable, the primary purpose of light palpation is not to reduce anxiety but to gather assessment data. Anxiety reduction is a secondary benefit rather than the main objective.

B. It helps identify areas of tenderness and abnormalities: Light palpation allows the nurse to feel surface characteristics, detect tenderness, and identify abnormalities such as masses or swelling. It is the initial step in palpation before progressing to deeper techniques, providing important information about the abdominal area.

C. It is the only technique used for abdominal assessment: Light palpation is just one technique. Deep palpation and other assessment methods like inspection, percussion, and auscultation are also necessary for a complete abdominal assessment.

D. It allows for the assessment of the abdominal organs: Assessment of deeper abdominal organs requires deep palpation, not light palpation. Light palpation primarily evaluates superficial structures and detects areas that may need further examination.

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A nurse is conducting several health assessments. Which action(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

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