A nurse is caring for a client who has depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?

Choice A reason:

Urine specific gravity should not be reported by the nurse. While urine specific gravity is an important indicator of hydration status and kidney function, the provided information does not suggest any abnormalities in urinary output or signs of kidney issues. It is not the most critical finding to report in this scenario.

Choice B reason:

Prealbumin should not be reported by the nurse. Prealbumin is a protein used to assess nutritional status, but its significance in this situation is not apparent from the provided data. It may be relevant in other contexts, such as assessing malnutrition, but it does not directly address the current findings.

Choice C reason:

Temperature should not be reported by the nurse. The provided information does not include any data about the client's temperature, and there are no signs of infection mentioned. While temperature is an important vital sign, it is not relevant to the findings presented in this scenario.

Choice D reason

The nurse should report the "hypoactive bowel sounds upon auscultation" to the provider. Hypoactive bowel sounds can be a sign of gastrointestinal (GI) motility issues, which may indicate a potential problem with the client's digestive system. It could be due to various causes such as bowel obstruction, inflammation, or other GI disorders. Reporting this finding to the provider is essential so that appropriate assessments and interventions can be taken to address the client's condition.

The correct answer is choice b. Performing indwelling urinary catheter care.

Choice A rationale:

Changing the appliance on a new colostomy is a complex task that requires assessment and education, which should be performed by a registered nurse (RN) or a licensed practical nurse (LPN).

Choice B rationale:

Performing indwelling urinary catheter care is a routine task that can be delegated to an assistive personnel (AP) as it involves basic hygiene and maintenance.

Choice C rationale:

Demonstrating how to use an incentive spirometer involves patient education and assessment of the patient’s technique, which should be done by an RN or LPN.

Choice D rationale:

Measuring the depth of a stage 3 pressure injury requires assessment skills and clinical judgment, which are beyond the scope of practice for an AP. This task should be performed by an RN or LPN.