A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

(A) Develop client-specific goals and outcomes: While this is an important step in the nursing process, it is not the first step. Before developing goals and outcomes, the nurse needs to understand the client’s situation, which in this case involves determining the nature of the client’s grief.

(B) Incorporate the treatment into the client’s care: Incorporating treatment into the client’s care is part of the implementation phase of the nursing process. Before this step, the nurse needs to assess the client’s condition and plan the care, which includes understanding the nature of the client’s grief.

(C) Determine whether coping strategies were successful: Determining the success of coping strategies is part of the evaluation phase of the nursing process. This is typically done after the implementation of care and treatment. It is not the first step in caring for a client experiencing grief.

(D) Establish whether the client’s grieving is healthy or complicated: This is the most appropriate answer. The first step in the nursing process is assessment. For a client experiencing grief, this would involve establishing whether the client’s grieving is healthy (a normal response to loss) or complicated (prolonged or more intense grief that may require additional support or intervention). This understanding will guide the subsequent steps of the nursing process, including planning care and setting goals.

B) "I will keep my house at a cool temperature": This statement indicates a need for further teaching because maintaining a warm environment is recommended for individuals with Raynaud's phenomenon to prevent vasoconstriction and reduce the risk of attacks. Cold temperatures can trigger symptoms in individuals with this condition. Therefore, advising the client to keep their house warm is appropriate and aligns with preventive measures for Raynaud's phenomenon.

A) "I will try to anticipate and avoid stressful situations": Stress management is an essential aspect of managing Raynaud's phenomenon, as stress can trigger vasospasms. Anticipating and avoiding stressful situations can help reduce the frequency and severity of symptoms.

C) "I will complete the smoking cessation program I started": Smoking cessation is crucial for individuals with Raynaud's phenomenon because smoking narrows blood vessels and exacerbates symptoms. Completing a smoking cessation program is a positive step toward reducing the risk of vasospasms.

D) "I will wear gloves when removing food from the freezer": Wearing gloves when handling cold objects, such as food from the freezer, is recommended for individuals with Raynaud's phenomenon to prevent triggering attacks due to exposure to cold temperatures. This statement demonstrates an understanding of preventive measures for managing the condition.