The nurse is completing an admission assessment for a client with a known history of depression and multiple, unexplained fractures. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?
Screen the client for domestic violence.
Determine the client's risk for suicide.
Ask client to state a chief complaint for admission.
Obtain a baseline set of vital signs.
The Correct Answer is D
Choice A rationale: Screening the client for domestic violence requires a more comprehensive assessment and interpretation of findings, which is beyond the scope of practice for the UAP.
Choice B rationale: Determining the client's risk for suicide involves complex judgment and should be assessed by a licensed healthcare provider, not a UAP.
Choice C rationale: Asking the client to state a chief complaint for admission involves initial communication and assessment skills, which should be performed by licensed nursing staff.
Choice D rationale: Obtaining a baseline set of vital signs is a routine task that can be delegated to the UAP. It is a non-complex and standard part of the admission process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Disrupting group activities is a concerning behavior but may not necessitate constant observation. The key is to assess the potential for harm to self or others.
Choice B rationale: Refusing antipsychotic medications is a significant concern, but it alone may not warrant constant observation. The nurse needs to assess the client's overall behavior and the potential for harm.
Choice C rationale: Wandering into clients' rooms poses a risk to the safety of both the client and others. This behavior indicates a need for constant observation to prevent harm or inappropriate interactions.
Choice D rationale: Talking with nonsensical words is a symptom of the client's mental health condition but may not be the sole criterion for constant observation. The nurse should assess the overall risk to safety.
Correct Answer is D
Explanation
Choice A rationale: Alkaline phosphatase is not typically associated with the monitoring of lithium therapy. The primary concern is renal function.
Choice B rationale: Blood glucose is not the most critical parameter to monitor before initiating lithium therapy. The focus is on renal function.
Choice C rationale: White blood count is not the primary laboratory value to assess before starting lithium. Renal function is more critical.
Choice D rationale: Serum creatinine is the most important laboratory finding to review before beginning lithium therapy. Lithium is primarily excreted by the kidneys, and impaired renal function can lead to lithium toxicity. Regular monitoring of renal function, including serum creatinine levels, is crucial to prevent adverse effects.
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