A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?

The client is pacing around the chair in which their partner is sitting.

Rationale:

• A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.
• B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.
• C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.
• D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.

The correct answers are A, B, and D.

Choice A reason:

Removing an indwelling urinary catheter when it is no longer indicated is a standard postoperative care practice. It helps to reduce the risk of urinary tract infections (UTIs), which are common complications associated with prolonged catheter use. The normal practice is to remove the catheter as soon as the patient can use the bathroom independently or when medically advised.

Choice B reason:

Elevating the affected limb at chest level can help reduce swelling and improve venous return. This is particularly important after surgery involving the lower extremities to prevent edema and promote circulation. Proper elevation assists in managing pain and preventing complications such as deep vein thrombosis (DVT).

Choice C reason:

Assisting with ambulation from bed to chair immediately after surgery may not be appropriate, especially if the adolescent has had surgery on the lower extremity. It is essential to wait for the physician's evaluation and specific instructions regarding weight-bearing and movement post-surgery.

Choice D reason:

Performing neurovascular assessments every hour is crucial after surgery on an extremity. This involves checking for sensation, motor function, color, temperature, capillary refill, and pulse strength. The normal capillary refill time is less than 2 seconds; a refill time of 4 seconds, as noted in the assessment, is abnormal and warrants close monitoring. Frequent assessments help in early detection of complications such as compartment syndrome.

Choice E reason:

Applying warm packs to the right extremity for the first 24 hours post-surgery is not recommended. Warm packs can increase circulation to the area, potentially increasing swelling and bleeding. Instead, cold packs are usually applied to reduce swelling and provide pain relief. The use of warm packs can be considered after the initial 24-hour period, depending on the surgeon's instructions and the wound's response.