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.

Answer and Explanation

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.

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Correct Answer is ["5"]

Explanation

Step 1: Determine the concentration of Heparin in units per mL. 25,000 units ÷ 250 mL = 100 units per mL Result: 100

Step 2: Determine the rate in mL per hour needed to deliver 500 units per hour. 500 units ÷ 100 units per mL = 5 mL per hour Result: 5 mL per hour

The nurse should set the infusion pump to deliver at a rate of 5 mL per hour.

A. My boyfriend is too passionate for me. B. Next time I won’t wear such a sexy dress. C. I know it was not my fault. D. I’ll just go on double dates from now on.

Correct Answer is C

Explanation

Choice A Reason: My boyfriend is too passionate for me

This statement indicates that the client is still placing some blame on their boyfriend’s behavior rather than recognizing the assault as a violation of their autonomy and consent. It suggests that the client may not fully understand that the responsibility for the assault lies with the perpetrator, not with their boyfriend’s level of passion. This mindset can hinder the healing process and indicates that the client may still be struggling with self-blame.

Choice B Reason: Next time I won’t wear such a sexy dress

This statement reflects a common misconception that the victim’s clothing or behavior can provoke sexual assault. It indicates that the client is still internalizing blame for the assault, believing that their attire was a contributing factor. This belief can be detrimental to recovery, as it perpetuates the myth that victims are responsible for the actions of their assailants.

Choice C Reason: I know it was not my fault

This statement is a strong indicator of progress in therapy. Recognizing that the assault was not their fault shows that the client is beginning to understand that the responsibility lies solely with the perpetrator. This realization is crucial for healing, as it helps to alleviate feelings of guilt and self-blame, allowing the client to move forward in their recovery.

Choice D Reason: I’ll just go on double dates from now on

This statement suggests that the client is still trying to find ways to prevent future assaults by changing their behavior rather than recognizing that the fault lies with the perpetrator. While taking precautions can be a part of feeling safe, it should not be based on the belief that the client could have prevented the assault by altering their actions.

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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):

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is to receive a continuous Heparin infusion at s00 units per hour. Pharmacy supplies Heparin in a concentration of 25,000 units per 250mL of NSS. Calculate the rate at which the nurse should set the infusion pump.

Correct Answer is ["5"]

Explanation

A college student experienced a sexual assault when out on a date. After several weeks of crisis intervention therapy, which statement by the client would indicate to the nurse that the student is making progress?

Correct Answer is C

Explanation

A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. What is/are the most appropriate nursing intervention(s)? (SELECT ALL THAT APPLY)

A fifteen-year-old was referred to the adolescent mental health clinic after being arrested for prostitution. The client’s parents reported that they have run away several times and are abusive towards them. The nurse should anticipate that the diagnosis will be:

A nurse is providing care for a client who is malnourished and appears exhausted. What data would cause the nurse to suspect the client is a victim of human trafficking? The client:

The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

When a client with a personality disorder uses self-destructive behavior as a way of getting needs met, the staff observe the behavior closely because:

A client with bipolar disorder is refusing to take mood stabilizers due to weight gain. To increase the patient’s adherence to a medication regimen, what measures could the nurse teach the client? (SELECT ALL THAT APPLY)

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):

Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)