A nurse is planning to delegate client care for several clients in a mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?
Witness an informed consent for a client who is scheduled for electroconvulsive therapy.
Explain the benefits of light therapy to a client who has depressive disorder.
Discuss the adverse effects of antianxiety medications with a client who has an anxiety disorder.
Participate in solitary activities with a client who has mania.
The Correct Answer is D
Choice A reason: Witnessing an informed consent is a legal process that typically requires a licensed nurse or healthcare provider to ensure that the client fully understands the procedure and its risks. It is not appropriate to delegate this task to assistive personnel.
Choice B reason: Explaining the benefits of light therapy involves providing health education, which should be done by a licensed nurse or healthcare provider who has the necessary knowledge and training to ensure accurate information is conveyed.
Choice C reason: Discussing the adverse effects of medications is part of medication education and should be conducted by a licensed nurse or healthcare provider. Assistive personnel are not trained to provide this level of detailed medical information.
Choice D reason: Participating in solitary activities does not require clinical judgment and can be safely delegated to assistive personnel. This task involves engaging the client in activities that can help manage their mania and provide a therapeutic environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement reflects a neutral observation of the client's behavior in therapy and does not indicate countertransference. Sharing feelings during group therapy sessions is a common and expected part of the therapeutic process, and the staff nurse's comment does not reveal any personal emotional response or projection onto the client.
Choice B reason: This statement is a clear example of countertransference. The staff nurse is identifying the client with a personal family member, which can cloud professional judgment. Such an emotional entanglement may lead to biased care, as the nurse may treat the client based on personal experiences with their brother rather than the client's individual needs and circumstances.
Choice C reason: Declining a client's inappropriate request for a date is a professional boundary that must be maintained. This statement does not reflect countertransference but rather appropriate professional conduct. It is important for the charge nurse to recognize that maintaining boundaries is crucial in a therapeutic setting, especially in cases of substance use disorder where clients may exhibit boundary-testing behaviors.
Choice D reason: This statement could be seen as a professional opinion regarding the client's need for accountability in their recovery process. It does not necessarily indicate countertransference unless the staff nurse's insistence on responsibility is driven by personal feelings or unresolved issues related to substance use.
Correct Answer is A
Explanation
Choice A reason: Constant talking is a common indicator of mania in individuals with bipolar disorder. During manic episodes, clients may experience pressured speech, which is fast, incessant, and difficult to interrupt. This symptom reflects the increased energy and reduced need for sleep that are characteristic of mania.
Choice B reason: While memory loss is not a definitive indicator of mania, it can occur in bipolar disorder. However, it is more commonly associated with either depressive episodes or the aftermath of a manic episode, rather than the manic phase itself.
Choice C reason: Excessive sleep is typically not associated with mania. In fact, a decreased need for sleep is one of the diagnostic criteria for a manic episode. Clients in a manic phase often feel rested after only a few hours of sleep.
Choice D reason: Expressing feelings of inferiority is not typically indicative of mania. Such feelings are more commonly associated with depressive episodes. Manic episodes often involve inflated self-esteem or grandiosity.
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