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

A. An overdose of cocaine can be lethal:
While this statement is accurate, it focuses on extreme outcomes rather than addressing the student's belief in their ability to control cocaine use. It may not encourage the student to reconsider their stance on trying the drug.

B. Addiction affects all aspects of one's life and one's family:
This response provides important information about the long-term consequences of addiction but does not directly counter the student's claim about their ability to control initial use. It may not be as impactful in the immediate context.

C. Denial of an addiction problem is often the first response to the behavior:
This response assumes the student is already using substances or experiencing addiction. It does not directly address the student's specific belief in their ability to control their actions after trying cocaine.

D. Mind-altering drugs take away one's ability to make good decisions:
This response is most appropriate because it directly challenges the student's confidence in their ability to control their behavior. It provides a logical explanation of why experimenting with cocaine is inherently risky, as it impairs judgment and decision-making, making it harder to "stop" as they claim

A. Ask the client about his recent substance use. B. Perform a mental status exam. C. Assess the client from head-to-toe. D. Determine the number of previous hospitalizations.

Correct Answer is B

Explanation

Choice A rationale: Asking the client about recent substance use is essential in assessing potential intoxication or withdrawal, which could contribute to the client's confused state. However, performing a mental status exam is the most important action to take.

Choice B rationale: The most important action for the nurse to take is to perform a mental status exam. This will help the nurse to assess the client's level of consciousness, orientation, memory, attention, mood, affect, thought process, and judgment. The mental status exam will also help the nurse to identify any signs of psychosis, delirium, dementia, or other mental disorders that may explain the client's behavior. Choice C rationale: Assessing the client from head-to-toe is a general nursing action but does not address the immediate need related to potential substance use. Choice D rationale: Determining the number of previous hospitalizations is relevant but does not address the current concern of substance use contributing to confusion.

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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

During a high school class on substance abuse, a student tells the group, "If I tried cocaine, I know I could handle it. I know when to stop." Which response is best for the nurse to provide?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

A client who is experiencing a severe level of anxiety and reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

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The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?

A client who has been taking clozapine reports experiencing a sore throat and has a temperature of 101.9° F (38.8° C). Which action should the nurse take?

An 18-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?