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The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)?

A.

Evaluate client teaching through return demonstration.

B.

Establish blood pressure parameters for client monitoring.

C.

Evaluate a staff member providing wound care.

D.

Measure the client's body weight each morning.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Evaluate client teaching through return demonstration: Evaluation of client teaching is a higher-level assessment requiring clinical judgment, which is within the RN's scope of practice. Practical nurses can reinforce teaching, but they do not evaluate comprehension independently.

B. Establish blood pressure parameters for client monitoring: Setting parameters for vital sign monitoring involves critical thinking and interpretation of the care plan or medical orders. This is the responsibility of the RN and should not be assigned to a PN.

C. Evaluate a staff member providing wound care: Staff evaluations, including assessing competency in procedures, are leadership responsibilities typically held by RNs or supervisors, not PNs. Delegating this to a PN may compromise quality assurance.

D. Measure the client's body weight each morning: This is a stable and routine task involving the collection of objective data. PNs are competent to perform and document such tasks, especially in long-term care where trends in weight are often monitored.


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Related Questions

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Rationale for Correct Choices:

  • Cortisol, epinephrine, and norepinephrine: These are key stress hormones activated during the fight-or-flight response. In PTSD, their persistent elevation is associated with symptoms like anxiety, agitation, and increased alertness, especially during perceived threats.
  • Hypervigilance: Hypervigilance refers to an enhanced state of sensory sensitivity and constant scanning of the environment for threats. It is a hallmark of PTSD, evident in the client's easily startled behavior and environmental scanning.

Rationale for Incorrect Choices:

  • Acetylcholine, epinephrine, and norepinephrine: Acetylcholine plays a greater role in attention and memory, not the stress response. Cortisol, not acetylcholine, is a more relevant hormone in PTSD-related hyperarousal and stress regulation.
  • Dopamine, norepinephrine, and epinephrine: While dopamine influences motivation and pleasure, cortisol is more directly tied to the physiological stress response seen in PTSD. Omitting cortisol weakens the connection to stress-induced hyperalertness.
  • Bradyphrenia: Bradyphrenia refers to slowed thinking, which is not typical in hyperaroused PTSD states. The client shows heightened awareness, not cognitive slowing.
  • Hypoactivity: Hypoactivity implies reduced movement or response, which does not align with the client’s constant environmental scanning and heightened alertness. Hyperactivity, not hypoactivity, is more consistent with hypervigilance.

Correct Answer is A

Explanation

Rationale:
A. Decrease consumption of red meat and most seafood: These foods are high in purines, which are metabolized into uric acid. Reducing purine intake helps lower uric acid levels, minimizing the frequency and severity of gout flares.

B. Support joints in an extended position while resting: Keeping joints in an extended position may worsen discomfort and inflammation. During acute attacks, joints should be rested in a slightly flexed, supported position to relieve pressure.

C. Massage joints to relax muscles and decrease pain: Massage of an inflamed joint during a gout attack can increase pain and inflammation. The affected area is usually extremely sensitive and should be protected, not manipulated.

D. Replace dietary table salt with salt substitutes: Salt substitutes often contain potassium, which can interact with medications like NSAIDs or ACE inhibitors. This recommendation is unrelated to gout management.

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