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Management of Care Rationale

1. A change in level of consciousness indicates delirium related to acute illness requiring assessment by a nurse. Other changes could be normal fluctuations. 2. Secrets are inappropriate in therapeutic relationships and counterproductive to care. Secrets may indicate risk of harm requiring understanding of rights, limits, and boundaries regarding confidentiality. 3. A UAP can perform standard, unchanging procedures like checking blood sugar every 2 hours with an Accu-Check.

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Yuuki Chitose (tai-kun)
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47 views2 pages

Management of Care Rationale

1. A change in level of consciousness indicates delirium related to acute illness requiring assessment by a nurse. Other changes could be normal fluctuations. 2. Secrets are inappropriate in therapeutic relationships and counterproductive to care. Secrets may indicate risk of harm requiring understanding of rights, limits, and boundaries regarding confidentiality. 3. A UAP can perform standard, unchanging procedures like checking blood sugar every 2 hours with an Accu-Check.

Uploaded by

Yuuki Chitose (tai-kun)
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Management of Care Rationale

1 C: was minimally responsive to voice and touch. A change in level of consciousness indicates delirium related to
acute illness. This would require the assessment of a nurse. The other changes could occur within the range of
normal fluctuations.

2 B: "I can’t make such a promise." Secrets are inappropriate in therapeutic relationships and are counter productive
to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The
nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality.

3 A: Test blood sugar every 2 hours by Accu-Check. The UAP can do standard, unchanging procedures.

4 B: A myocardial infarction that is free from pain and dysrhythmias. This client is the most stable with minimal risk of
complications or instability. The nurse can utilize basic nursing skills to care for this client.

5 D: Apply and care for a client''s rectal pouch. The RN may delegate the application and care of rectal pouches to a
UAP. This is an uncomplicated, routine task.

6 B: Recheck temperature 15 minutes after removing hot liquids from the bedside. Recheck temperature to eliminate
possible artificial elevation of temperature. Hot liquids, smoking, eating, chewing gum, and talking can all elevate
temperature. Waiting to take the temperature for 15 minutes will help the temperature return to its normal, in order to
get an accurate reading. Avoid premature assumptions about explanations for findings. The other options are
incorrect.

7 D: Perform nostril and mouth care. Skin care around a nasogastric tube is a routine task that is appropriate for
UAPs. The other tasks would be appropriate for a PN or RN to do since they are advanced skills or require
evaluation.

8 C: Obtain more details of the client’s claim of abuse. The advocacy role of the professional nurse as well as the
legal duty of the reasonable prudent nurse requires the investigation of claims of abuse or violation of rights. The
nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the
nurse gather more information, further assessment, before documentation or the reporting of the complaint.

9 A: Normal patterns of behavior may be labeled as deviant, immoral, or insane. Culture is an important variable in
the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive
qualities.

10 C: Care for a client with discharge orders. A registered nurse (RN) is the best person to do teaching or evaluation
that is needed at time of discharge.

11 D: Supervise a nursing assistant for skin care. The nursing assistant can inspect the skin while giving hygiene
care, but the nurse should supervise skin care since assessment and analysis are needed.

12 B: Assign 1 of the nursing staff to visit the client regularly. Regular, frequent, planned contact by 1 staff member
provides continuity of care and communicates to the client that care will be available when needed.

13 B: The client has a right to know about the prescribed medications. Clients have a right to informed consent which
includes information about medications, treatments, and diagnostic studies.

14 C: Irrigate and redress a leg wound. The PN is a licensed provider and can perform this complex task. Options A
and B could be delegated to an unlicensed assistive personnel (UAP), and option D requires an RN.

15 D: "Have you reviewed the list of expected skills you might need on this unit?". The UAP must be competent to accept the
delegated task. Review of skills needed versus level of performance is the most efficient and effective way to determine this.

16 D: In order to release information about a client there must be a signed consent form with designation of to whom
information can be given, and what information can be shared.

17 D: Discuss the boundaries of the therapeutic relationship with the client. The nurse-client relationship is one with
professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust.

18 A: Give clear information to the UAP about what is expected for client safety.

19 C: "He may be scared and taking it out on you. Let''s talk to figure out what to do." This response explains the
client''s behavior without belittling the UAP’s feelings. The UAP is encouraged to contribute to the plan of care to help
solve the problem.
20 B: A middle-aged client with an obsessive compulsive disorder. The UAP can be assigned to care for a client with
a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition.

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