Psychiatric care technicians (PCTs) are unlicensed assistive personnel that are an integral part of the acute care mental healthcare team. Which of the following choices would be an example(s) of overdelegation by the nurse to a PCT? The nurse directs the PCT to (Select All that Apply):
Perform a neurological assessment on a patient in seclusion to compare the nurse’s findings.
Play cards with 3 patients during unstructured time.
Review follow-up care with a patient about to be discharged.
Set a goal for the day for a patient with a borderline personality disorder.
Obtain a weight on a patient with bipolar disorder in a hypomanic state.
Correct Answer : A,C,D
Choice A Reason: Perform a neurological assessment on a patient in seclusion to compare the nurse’s findings
This task is an example of overdelegation. Performing a neurological assessment requires specialized knowledge and skills that are beyond the scope of practice for unlicensed assistive personnel. Such assessments should be conducted by a licensed nurse or healthcare provider to ensure accuracy and appropriate clinical judgment.
Choice B Reason: Play cards with 3 patients during unstructured time
This task is appropriate for a PCT. Engaging patients in recreational activities like playing cards does not require specialized clinical skills and falls within the scope of practice for unlicensed assistive personnel. It helps in providing social interaction and can be beneficial for the patients’ mental health.
Choice C Reason: Review follow-up care with a patient about to be discharged
This task is an example of overdelegation. Reviewing follow-up care involves providing important information about the patient’s ongoing treatment and care plan, which requires clinical knowledge and the ability to answer any questions the patient may have. This responsibility should be handled by a licensed nurse or healthcare provider.
Choice D Reason: Set a goal for the day for a patient with a borderline personality disorder
This task is also an example of overdelegation. Setting therapeutic goals for patients, especially those with complex mental health conditions like borderline personality disorder, requires clinical expertise and an understanding of the patient’s treatment plan. This should be done by a licensed nurse or mental health professional.
Choice E Reason: Obtain a weight on a patient with bipolar disorder in a hypomanic state
This task is appropriate for a PCT. Obtaining a patient’s weight is a routine task that does not require specialized clinical skills and falls within the scope of practice for unlicensed assistive personnel. It is a straightforward task that can be safely delegated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is b. Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone.
Choice A Reason: Get the defibrillator to the patient’s bedside and open the crash cart
While having the defibrillator and crash cart ready is important in emergency situations, it is not the immediate priority in this scenario. The patient’s symptoms suggest opioid overdose, which requires immediate intervention to support breathing and reverse the effects of the opioid. The primary focus should be on ensuring adequate oxygenation and administering naloxone.
Choice B Reason: Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone
This is the correct answer. The patient’s blue-tinged lips, slowed respirations, and pinpoint pupils are indicative of opioid overdose. Administering oxygen via a 100% nonrebreather mask helps to ensure adequate oxygenation, while placing an IV catheter allows for the administration of naloxone, an opioid antagonist that can reverse the effects of the overdose. This intervention addresses the immediate life-threatening condition.
Choice C Reason: Administer naloxone intranasally if there is not an IV catheter in place
While administering naloxone intranasally is an appropriate alternative if IV access is not available, it is not the first priority. The initial focus should be on ensuring adequate oxygenation and establishing IV access for more effective administration of naloxone. If IV access cannot be quickly established, then intranasal naloxone can be used.
Choice D Reason: Contact the patient’s parents or legal guardian for consent to treat
Obtaining consent is important, but it is not the immediate priority in a life-threatening situation. The nurse’s primary responsibility is to stabilize the patient and address the acute medical emergency. Once the patient is stabilized, the nurse can then contact the parents or legal guardian for further consent and information.
Correct Answer is C
Explanation
Choice A Reason:
Emotional injury and learned helplessness. While emotional injury and learned helplessness are significant consequences of intimate partner violence (IPV), they are not the central factors driving the dynamic of IPV. Learned helplessness refers to a state where the victim feels powerless to change their situation due to repeated exposure to traumatic events. Emotional injury is a result of the abuse but not a driving factor.
Choice B Reason:
Poor communication and social isolation. Poor communication and social isolation can exacerbate the situation but are not the primary factors central to the dynamic of IPV. Social isolation is often a tactic used by abusers to control their victims, but it is a consequence rather than a cause. Poor communication can contribute to misunderstandings and conflicts but is not the root cause of IPV.
Choice C Reason:
Power and control. This statement is correct. The central dynamic of intimate partner violence is the abuser’s desire to exert power and control over their partner. This need for dominance manifests through various abusive behaviors, including physical, emotional, psychological, and financial abuse. The Power and Control Wheel, a tool developed by the Domestic Abuse Intervention Project, illustrates how different abusive tactics are used to maintain control over the victim.
Choice D Reason:
Erratic relationships and vulnerability. Erratic relationships and vulnerability are characteristics often seen in IPV situations but are not central to the dynamic. Vulnerability can make individuals more susceptible to abuse, and erratic relationships can be a symptom of the abuse, but they do not drive the abusive behavior5.
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