A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

Obtaining the initial assessment of assigned clients

Changing a nonsterile dressing

Interpreting a client’s diagnostic laboratory results

Educating a client and family members on home care

Answer and Explanation

The Correct Answer is B

Choice A reason: Obtaining initial assessments requires clinical judgment and is outside the scope of assistive personnel (AP). Registered nurses must perform assessments to identify health changes accurately. Delegating this task violates scope of practice regulations, making it illegal and unsafe for AP to perform.
Choice B reason: Changing a nonsterile dressing is within the scope of assistive personnel, as it involves routine, non-invasive care under nurse supervision. AP are trained for such tasks, which do not require clinical judgment, making this a legal and appropriate delegation choice.
Choice C reason: Interpreting laboratory results requires advanced knowledge and clinical decision-making, reserved for registered nurses or providers. Assistive personnel lack the training to analyze results, so delegating this task is illegal and risks patient safety, making it an incorrect choice.
Choice D reason: Educating clients and families involves assessing learning needs and tailoring information, which requires nursing judgment. Assistive personnel are not trained for patient education, making this task outside their scope and illegal to delegate, thus an incorrect choice.

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

Explanation

Choice A reason: Persistent anger about the hurricane is a PTSD symptom, reflecting emotional dysregulation and hyperarousal post-trauma. This ongoing distress, per DSM-5 criteria, warrants referral for mental health evaluation to address potential PTSD, making it a correct indicator for intervention.
Choice B reason: Realizing life will not return to normal is a realistic adjustment, not necessarily a PTSD symptom. Without additional distress indicators, this does not meet diagnostic criteria for PTSD, making it incorrect for requiring a referral in this context.
Choice C reason: Moving to higher ground is a practical response to reduce future risk, not a PTSD symptom. It reflects adaptive coping rather than psychological distress, so it does not warrant a referral for PTSD assessment, making it incorrect.
Choice D reason: Frequent nightmares about the hurricane are a hallmark PTSD symptom, classified as intrusive re-experiencing per DSM-5. This significant distress disrupts sleep and daily functioning, necessitating a referral for mental health evaluation, making it a correct choice.
Choice E reason: Feeling disconnected from others indicates emotional numbing, a PTSD avoidance symptom per DSM-5. This social withdrawal post-hurricane suggests significant psychological impact, warranting a referral for PTSD assessment to address underlying trauma, making it correct.

A. I prefer to wear loose clothing to hide my scars. B. I am ready to join a support group for cancer survivors. C. I feel confident about my recovery process. D. I am planning to resume my exercise routine next week.

Correct Answer is A

Explanation

Choice A reason: Preferring loose clothing to hide scars indicates an altered body image, as it reflects discomfort with physical changes post-mastectomy. This behavior suggests emotional distress about appearance, a common response to surgical body alterations, making it the correct indicator.
Choice B reason: Joining a support group shows proactive coping and acceptance, not necessarily an altered body image. It reflects social engagement and resilience, not distress about physical changes, making it incorrect for indicating body image concerns.
Choice C reason: Feeling confident about recovery suggests positive adjustment, not an altered body image. Confidence indicates emotional resilience rather than distress about physical appearance post-mastectomy, making this statement incorrect for this concern.
Choice D reason: Planning to resume exercise indicates focus on recovery and health, not body image distress. This proactive attitude reflects physical rehabilitation goals, not emotional concerns about appearance, making it incorrect for altered body image.

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A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of post-traumatic stress disorder? (Select all that apply)

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

Explanation

A nurse is caring for a client who has breast cancer and is postoperative following a bilateral mastectomy. Which of the following statements indicates the client has an altered body image?

Correct Answer is A

Explanation

A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?

A nurse is preparing a sterile field for a client who requires a sterile procedure. Which of the following actions should the nurse plan to take?

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

A nurse is discussing strategies for cost containment with a group of nurse managers. Which of the following statements should the nurse include?

A nurse is preparing to assess a client for a pulse deficit. Which of the following actions should the nurse plan to take?

A nurse is evaluating a client who received intermittent IV fluids. Which of the following findings indicates the client has a fluid overload?

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