A nurse is assisting with the care of a client who is experiencing a cardiac arrest. Which of the following tasks should the nurse assign to an assistive personnel?

Client 1 (First Priority):

• Experiencing command hallucinations: Command hallucinations are auditory hallucinations that instruct the client to harm themselves or others, posing an immediate safety concern.
• Potential risk of self-harm: Persecutory delusions and statements indicating "the agents are watching" suggest escalating paranoia, increasing the risk of dangerous behaviors or impulsive self-protective actions. Immediate intervention is essential to prevent harm.

Client 2 (Lower Priority):

• Stopped taking medication: Non-compliance with medication has led to severe depressive symptoms, including isolation, withdrawal, and psychomotor retardation.
• Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment. However, this client requires evaluation soon after Client 1.

Client 3 (Lowest Priority):

• Low lithium level (0.7 mEq/L): This level is slightly below the therapeutic range (0.8 to 1.2 mEq/L) but not critically dangerous.
• Increased risk of agitation and instability: The symptoms of agitation and poor sleep are concerning, but immediate safety threats are less imminent compared to command hallucinations.

A. Taking the vital signs of a client who is experiencing acute angina. Acute angina is a potentially unstable condition requiring assessment by a nurse.
B. Collecting a urine specimen from a client who is experiencing dysuria. APs can perform routine specimen collection tasks.
C. Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure. Only licensed nurses should provide pre-procedure instructions.
D. Reinforcing teaching with a client about stool specimen collection. Reinforcement of teaching involves assessment and evaluation, which are the nurse’s responsibilities.