For a client with a suspected adrenal gland tumor, which action is appropriate for delegation to the nursing assistant?

For a client with a suspected adrenal gland tumor, which action is appropriate for delegation to the nursing assistant?

• A. Assess skin turgor and mucous membranes.
• B. Discuss the dietary restrictions needed for 24-hour urine testing.
• C. Plan ways to control the environment that will avoid stimulating the client.
• D. Remind the client to avoid drinking coffee and changing position suddenly.

Answer: (D)

The main idea here is safe delegation to a nursing assistant for a situation where stimulation can trigger dangerous responses. A tumor of the adrenal gland, such as pheochromocytoma, causes excess catecholamine release. Substances like caffeine and abrupt changes in position can provoke a surge in blood pressure and heart rate, leading to a hypertensive crisis. Because of this, the most appropriate action for a nursing assistant is to reinforce simple, nonclinical safety instructions that don’t require clinical judgment. Reminding the client to avoid drinking coffee and to avoid changing position suddenly is a straightforward safety cue. It reduces potential triggers without needing assessment, interpretation, or planning by a licensed nurse, which fits the nursing assistant’s scope of practice. The other tasks involve nursing assessment, detailed patient teaching, or care planning. Assessing skin turgor and mucous membranes requires evaluation of hydration status. Discussing dietary restrictions for a 24-hour urine test involves interpreting test requirements and providing comprehensive education. Planning environmental controls to minimize stimulation requires nursing judgment and coordination. These go beyond what a nursing assistant is typically asked to do.

The main idea here is safe delegation to a nursing assistant for a situation where stimulation can trigger dangerous responses. A tumor of the adrenal gland, such as pheochromocytoma, causes excess catecholamine release. Substances like caffeine and abrupt changes in position can provoke a surge in blood pressure and heart rate, leading to a hypertensive crisis. Because of this, the most appropriate action for a nursing assistant is to reinforce simple, nonclinical safety instructions that don’t require clinical judgment.

Reminding the client to avoid drinking coffee and to avoid changing position suddenly is a straightforward safety cue. It reduces potential triggers without needing assessment, interpretation, or planning by a licensed nurse, which fits the nursing assistant’s scope of practice.

The other tasks involve nursing assessment, detailed patient teaching, or care planning. Assessing skin turgor and mucous membranes requires evaluation of hydration status. Discussing dietary restrictions for a 24-hour urine test involves interpreting test requirements and providing comprehensive education. Planning environmental controls to minimize stimulation requires nursing judgment and coordination. These go beyond what a nursing assistant is typically asked to do.