A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.)
Check the position of a client in soft wrist restraints.
Accompany a client who has depression to occupational therapy.
Set limits with a client who has mania.
Sit with a client who has alcohol use disorder and whose last drink was five days ago.
Assess a client who has hypomania for exhaustion.
Correct Answer : A,B,D
Rationale:
A. Check the position of a client in soft wrist restraints is appropriate for an AP as it involves routine monitoring and ensuring the client's safety.
B. Accompany a client who has depression to occupational therapy is a task that can be assigned to an AP, as it involves providing support and ensuring the client's safe arrival to therapy.
C. Set limits with a client who has mania is not appropriate for an AP, as this involves therapeutic communication and behavior management, which requires nursing judgment.
D. Sit with a client who has alcohol use disorder and whose last drink was five days ago can be assigned to an AP as it involves providing a supportive presence and monitoring, but the nurse should assess for withdrawal symptoms.
E. Assess a client who has hypomania for exhaustion is a nursing responsibility that involves evaluation and judgment, making it inappropriate to delegate to an AP.
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Correct Answer is A
Explanation
Rationale:
A. "The client must provide permission to share the records with you." is the correct procedure as medical records are confidential and require patient consent for release to family members.
B. I will ask the nursing supervisor to obtain the medical records for you is not correct unless the client has given permission.
C. The health care provider will share this information with you does not address the need for patient consent.
D. The ethics committee will need to approve this request for you is not apptlicable; consent from the client is required.
Correct Answer is B
Explanation
Rationale:
A. "I am sure these feelings will pass once you go home." is dismissive and does not address the client's current emotional state.
B. "Tell me what you understand about your illness." opens up a dialogue for the client to express their feelings and concerns, which can help in assessing their emotional state and providing support.
C. "Tell me why you feel hopeless." might be too direct and could make the client feel pressured.
D. "If I were you, I would ask for a referral to hospice care." could be perceived as judgmental and does not address the client’s immediate feelings of hopelessness.