The nurse reviews the Nurses' Notes from Day 1 at 1100.
Encourage the client to discuss feelings of new eating patterns.
Discuss measures to assist the client to develop a positive body image
Consult the dietitian to determine the client's caloric intake.
Identify thoughts that reinforce disordered eating patterns.
Observe the client during meals.
Accompany the dient to the restroom following meals.
Use cognitive behavioral techniques to address the client's behavior
Check the client's vital signs
Perform daily weights.
Correct Answer : E,F,H,I
Rationale:
A. Encourage the client to discuss feelings of new eating patterns: This requires therapeutic communication and assessment skills, which are beyond the scope of assistive personnel. Such discussions should be initiated and guided by the nurse or mental health professionals.
B. Discuss measures to assist the client to develop a positive body image: Promoting positive self-image involves complex therapeutic techniques and individualized planning, which must be performed by licensed staff, not delegated to assistive personnel.
C. Consult the dietitian to determine the client's caloric intake: Contacting other members of the healthcare team for clinical collaboration is the nurse’s responsibility. This involves interpretation of data and coordination of care, which cannot be delegated.
D. Identify thoughts that reinforce disordered eating patterns: Recognizing cognitive distortions requires clinical judgment and is a core part of therapeutic nursing or psychological care. It cannot be delegated to assistive personnel.
E. Observe the client during meals: Assistive personnel can monitor the client while eating to help prevent purging behaviors. Meal observation is a standard component of bulimia nervosa management and does not require clinical decision-making, making it appropriate for delegation.
F. Accompany the client to the restroom following meals: Clients with bulimia may attempt to purge after eating, so monitoring them post-meal is critical. This task involves supervision rather than evaluation and is suitable for assistive personnel under nursing guidance.
G. Use cognitive behavioral techniques to address the client's behavior: CBT strategies are specialized interventions requiring advanced training, typically carried out by licensed nurses, therapists, or psychologists. These are not within the role of assistive personnel.
H. Check the client’s vital signs: Vital signs collection is a routine task that falls within the scope of assistive personnel when the client is stable. The nurse remains responsible for interpreting any abnormalities.
I. Perform daily weights: Weighing the client is a routine, objective measurement that does not require nursing judgment. It is appropriate to delegate this task as long as the AP follows the nurse’s instructions on timing and procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Rationale for Correct Answers:
1. Condition: Mastitis
Mastitis is an infection of the breast tissue that commonly affects breastfeeding women. It often occurs when bacteria (usually Staphylococcus aureus) enter through a cracked or damaged nipple, allowing pathogens to travel into the milk ducts. Symptoms can start with nipple pain and breast tenderness, progressing to flu-like symptoms, localized redness, and fever if untreated.
2. Evidence: Cracked nipple
The client's report of nipple discomfort throughout feeding and visible crack noted on the left nipple are red flags for potential bacterial entry, placing her at high risk for mastitis. Cracked nipples are common in breastfeeding, especially when there is poor latch or prolonged feeding.
Rationale for Incorrect Options:
Endometritis: This is an infection of the uterine lining. However, this client is 2 weeks postpartum, denies abdominal pain, and has normal lochial progression (whitish-yellow discharge = lochia alba). Her uterus is no longer palpable, indicating appropriate involution. No signs of fever, foul-smelling discharge, or uterine tenderness are noted.
Perineal hematoma: This would present with significant perineal pain, swelling, and possibly bluish discoloration. This client reports only mild perineal discomfort (2/10), likely related to normal healing from her episiotomy.
Group B streptococcus: The client tested negative for Group B Streptococcus. Moreover, GBS is not directly related to cracked nipples or mastitis.
Large for gestational age newborn: While the newborn was indeed LGA, this mainly increases the risk for perineal trauma or shoulder dystocia, not directly mastitis.
Correct Answer is B
Explanation
Rationale:
A. Autonomy: Autonomy involves respecting a client’s right to make their own healthcare decisions. While important, this scenario concerns unequal treatment rather than limiting the clients’ decision-making rights.
B. Justice: Justice refers to fairness and equity in the distribution of healthcare resources. Providing supplies to one client based on insurance status while denying them to another reflects unequal and unethical treatment, violating the principle of justice.
C. Beneficence: Beneficence means acting in the best interest of the client by promoting well-being. Although the insured client is benefitting, failing to support the uninsured client equally undermines the overall intent to do good for all clients.
D. Nonmaleficence: Nonmaleficence is the obligation to do no harm. While denying supplies could lead to harm, the primary ethical breach in this situation lies in the unfair distribution of care, which relates more directly to justice.
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