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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is B. Obtain a prescription for seclusion within 30 minutes. This ensures the seclusion is legally and ethically justified.

Choice A reason:

Keeping the client in seclusion for no longer than 6 hours is incorrect because the maximum duration for seclusion without reassessment is typically 4 hours for adults.

Choice B reason:

Obtaining a prescription for seclusion within 30 minutes is correct as it ensures the seclusion is legally and ethically justified.

Choice C reason:

Monitoring the client's vital signs every 4 hours is incorrect because vital signs should be monitored more frequently, usually every 15 minutes to 1 hour.

Choice D reason:

Documenting the client's behavior every 60 minutes is incorrect because documentation should occur more frequently, typically every 15 minutes.

A. "Have you talked to your family about your diagnosis?" B. "These feelings are an expected part of anticipatory grieving." C. "I'm sure the nurses are trying to take good care of you." D. "Can you tell me more about what is upsetting you?"

Correct Answer is D

Explanation

Choice A reason: While discussing the client's diagnosis with their family could be part of the care process, it does not address the client's immediate concern about the quality of care they are receiving. This response does not validate the client's feelings or provide an opportunity for them to elaborate on their concerns.

Choice B reason: Telling the client that their feelings are part of anticipatory grieving may be true, but it can come across as dismissive and does not offer support for the specific issue the client has raised about the quality of care.

Choice C reason: Assuring the client that the nurses are trying to provide good care does not acknowledge the client's perception of inadequate care. It's important to validate the client's feelings and understand their perspective before offering reassurances.

Choice D reason: Asking the client to elaborate on their concerns shows empathy and a willingness to listen. It allows the nurse to gather more information about the client's experience and identify specific areas that may need improvement in the care provided.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is caring for a client who has been placed in seclusion following an acute violent episode. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving end-of-life care. The client states, "The nurses here don't do a good job caring for me." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make?

A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take?

A nurse is caring for a client who is seeking help to quit smoking. Which of the following prescriptions should the nurse expect the provider to prescribe?

A nurse is assessing a client who has been receiving electroconvulsive therapy (ECT). Which of the following findings indicates the treatment is effective?

A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when supporting the client's refusal of medications?

A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, "I think my blackouts are actually caused by low blood sugar." The nurse should recognize the client is using which of the following defense mechanisms?