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.

Answer and Explanation

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.

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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.

A. Involve her in group therapy. B. Praise her for the new behavior. C. Observe her actions continuously. D. Offer her a choice of activities.

Correct Answer is C

Explanation

Choice A rationale: Involving her in group therapy may be premature, as the client has just started to exhibit changes in behavior. Continuous observation is necessary to assess the nature and sustainability of these changes.

Choice B rationale: Praising her for the new behavior is positive, but continuous observation is essential to monitor for any signs of escalating or problematic behavior.

Choice C rationale: Observing her actions continuously is the most appropriate action at this point. The nurse needs to monitor the client closely to assess the nature of the changes, ensuring they are not indicative of increased agitation or potential harm.

Choice D rationale: Offering her a choice of activities may be appropriate once the nurse has a better understanding of the clien's current state. However, continuous observation is the priority.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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