Which aspect of nursing would most likely be defined by legislation at the state level?
Criteria that a nurse must consider when delegating tasks to unlicensed assistive personnel
Criteria that clients must meet to qualify for Medicare or Medicaid
Differences in scope of practice between registered nurses and licensed practical nurses
The process that nurses must follow when handling and administering medications
The Correct Answer is C
A. Delegation guidelines may be influenced by organizational policy but are often based on state nurse practice acts.
B. Medicare and Medicaid qualification criteria are defined at the federal level, not state.
C. Scope of practice differences between registered nurses and licensed practical nurses are established by state legislation, which regulates nursing practice within the state.
D. Medication administration processes can be guided by federal laws and facility policies but are also regulated by state laws; however, the clear differentiation of scope of practice is specifically legislated at the state level.
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Correct Answer is C
Explanation
A. While clients may belong to multiple cultural groups, this is only one part of understanding them.
B. Cultural behaviors can vary by situation, but this is a subset of a broader approach.
C. The most important aspect is recognizing the client as an individual, with unique beliefs and needs, even within their cultural context. This prevents stereotyping and promotes personalized care.
D. Viewing the client only as a representative of a cultural group risks stereotyping and overlooks individual differences.
Correct Answer is B
Explanation
A. While loneliness can contribute to distress, the specific behaviors observed (excessive religious reading, crying, and poor sleep) suggest something deeper than just social isolation.
B. These behaviors are signs of spiritual distress, which may occur when a person is facing a serious illness or surgery and is struggling with questions of meaning, faith, or fear. Spiritual distress can manifest emotionally and behaviorally, as seen here.
C. While some anxiety is expected before major surgery, persistent emotional signs like excessive crying and poor sleep, along with intense religious focus, indicate more than normal preoperative nerves.
D. Labeling the client as “naturally emotional” is an assumption and dismisses the need for assessment and appropriate support.
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