A nurse in an outpatient mental health clinic is caring for a client.

Exhibit 1

Vital Signs

3 months ago:

Blood pressure 116/68 mm Hg

Heart rate 82/min

Respiratory rate 16/min

Temperature 36.7° C(98.1° F)

SaO2 97% on room air

Today:

Blood pressure 128/76 mm Hg

Heart rate 104/min

Respiratory rate 22/min

Temperature 37.4° C(99.4° F)

SaO2 97% on room air

Exhibit 2

Nurses' Notes

3 months ago:

Client recently admitted with new diagnosis of schizophrenia. Received inpatient treatment for 10 days and was discharged 1 week ago. Client is alert and oriented to person, place, time, and situation. Responds appropriately to questions. Client reports sleeping well and working at a local retail store.

Today:

Client presents for follow-up visit. Pressured speech noted.

Appears to be listening to unseen others. Client is restless.

Frequently getting out of chair. Appears tired and disheveled.

Exhibit 3

Graphic Record

3 months ago:

83.9 kg (185 lb)

Today:

83 kg(183 lb)

A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.

A. Instructing the client about the importance of regular medical appointments is important but not the priority because it is a secondary prevention strategy that aims to detect and treat any complications or changes in the client's condition early. The client should have regular follow-up visits with an endocrinologist, a diabetes educator, an ophthalmologist, a podiatrist, a dentist, and other health care providers as needed.

B. Encouraging the client to participate in daily exercise is important but not the priority because it is a tertiary prevention strategy that aims to reduce disability and improve quality of life for clients with chronic conditions. Exercise can help lower blood glucose levels, improve insulin sensitivity, reduce cardiovascular risk factors, enhance mood, and promote weight management for clients with type 1 diabetes mellitus. The client should consult with their health care provider before starting an exercise program and follow safety guidelines such as checking blood glucose levels before and after exercise, wearing appropriate footwear and clothing, carrying a source of fast-acting carbohydrate, and staying hydrated.

C. Explaining proper foot care techniques to the client is important but not the priority because it is a tertiary prevention strategy that aims to prevent or minimize complications such as foot ulcers, infections, and amputations for clients with type 1 diabetes mellitus. Foot care includes inspecting feet daily for any injuries or abnormalities, washing feet with mild soap and warm water, drying feet thoroughly especially between toes, applying moisturizer to prevent dryness and cracking, trimming toenails straight across and filing edges smooth, wearing clean cotton socks and well-fitting shoes, avoiding walking barefoot or exposing feet to extreme temperatures or pressure, and seeking medical attention for any foot problems.

D. Ensuring that the client understands the medication regimen is the nurse's priority because type 1 diabetes mellitus requires lifelong insulin therapy to maintain blood glucose levels within normal range and prevent complications such as ketoacidosis, hypoglycemia, and organ damage. The client needs to know how to administer insulin injections, monitor blood glucose levels, adjust insulin doses according to carbohydrate intake and physical activity, recognize and treat signs and symptoms of hypo- and hyperglycemia, and store insulin properly.

A. Incorrect. Performing gastrostomy feedings is a complex task that requires specialized training and assessment skills. The nurse should not delegate this task to an AP who has not received the appropriate education and competency validation.

B. Correct. Determining if the PRN pain medication has helped is a simple task that involves asking the client about their pain level and documenting the response. The nurse can delegate this task to an AP as long as they follow up with the client and evaluate the effectiveness of the pain management plan.

C. Incorrect. Providing instructions about client care to a family member over the telephone is a task that requires clinical judgment and communication skills. The nurse should not delegate this task to an AP who might not have the knowledge or authority to answer questions or address concerns.

D. Incorrect. Teaching a client how to measure their own blood pressure is a task that requires teaching and evaluation skills. The nurse should not delegate this task to an AP who might not be able to explain the procedure, demonstrate the technique, or assess the client's learning.