A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP).
Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?

The task involves making ongoing judgments about client data.

The task is within the AP’s range of function to perform.

The task can be performed in the same manner for most clients.

The task requires a specific sequence of steps.

Answer and Explanation

The Correct Answer is A

The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.

Choice B is wrong because the task is within the AP’s range of function to perform.

This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.

Choice C is wrong because the task can be performed in the same manner for most clients.

This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.

Choice D is wrong because the task requires a specific sequence of steps.

This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.

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Correct Answer is C

Explanation

Collaborate with the client to develop a daily physical exercise routine. This intervention can help reduce aggression and impulsivity in schizophrenia by providing an outlet for frustration, enhancing self-esteem, and improving mood. Physical exercise can also improve physical health and reduce the risk of metabolic syndrome associated with antipsychotic medications.

Choice A is wrong because warning the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination is punitive and threatening. This can increase the client’s anxiety, paranoia, and hostility, and may worsen the psychotic symptoms. Seclusion should only be used as a last resort when the client poses a serious danger to self or others, and not as a punishment or coercion.

Choice B is wrong because keeping the facility’s security personnel constantly visible to the client throughout treatment is intimidating and stigmatizing. This can also increase the client’s fear, distrust, and resentment, and may trigger aggressive behavior. Security personnel should only be involved when there is an imminent risk of violence, and not as a routine measure.

Choice D is wrong because agreeing that the hallucinations are real if the client exhibits aggressive behavior toward other clients is reinforcing the delusional belief and rewarding the aggression. This can also confuse the client and undermine the therapeutic relationship.

The nurse should acknowledge the client’s experience of hallucinations, but not endorse them as reality. The nurse should also set clear limits on aggressive behavior and use de-escalation techniques to calm the client.

A. Provide a brief description of the client’s diagnosis. B. Discuss suggestions for continuing the client’s care. C. State the client’s most recent vital signs. D. Review the client’s pertinent medical history.

Correct Answer is B

Explanation

The nurse should give report using the SBAR Communication tool in the following order: Situation, Background, Assessment, Recommendation. This tool provides a framework for communication between members of the health care team about a patient’s condition. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team.

Choice A is wrong because it is part of the Background section of the SBAR tool, which comes after the Situation section.

Choice C is wrong because it is part of the Assessment section of the SBAR tool, which comes after the Background section.

Choice D is wrong because it is also part of the Background section of the SBAR tool, which comes after the Situation section.

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A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP). Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a newly-admitted client who has schizophrenia and a history of aggressive behavior. Which of the following interventions should the nurse include in the initial plan?

Correct Answer is C

Explanation

A nurse is preparing to provide report on a client using the Situation-Background- Assessment-Recommendation (SBAR) Communication tool. Identify the order in which the nurse should give report.

Correct Answer is B

Explanation

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A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP).
Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?