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 B
Explanation
Choice A rationale: While assessing for symptoms of cocaine withdrawal is important, educating the client about the purpose and side effects of the medication is the priority when initiating new pharmacological treatment.
Choice B rationale: Educating the client about the purpose and side effects of the medication promotes understanding and adherence to the treatment plan, addressing the client's cravings.
Choice C rationale: Encouraging the client to take the medication as prescribed is important, but educating them about the medication takes precedence.
Choice D rationale: Determining when the client last used cocaine is relevant but does not directly address the education needed for medication management.
Correct Answer is B
Explanation
Choice A rationale: Telling the client they are out of control may escalate the situation and provoke further aggression. It is not a therapeutic or de-escalation technique.
Choice B rationale: Staying quietly with the client is a calm and non-confrontational approach. It allows the client to express emotions while conveying a supportive presence.
Choice C rationale: Distracting the client by offering finger foods may not be appropriate during a shouting episode, as it may be perceived as dismissive of the client's feelings or concerns.
Choice D rationale: Ignoring the client's acting-out behavior is not the best option. The nurse should acknowledge the client's emotions and provide support rather than ignoring the distress.
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