A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

Rationale:

A. Obtain a 12-lead ECG for the client: An ECG is important for diagnosing myocardial ischemia or infarction, but it is not the immediate first step. The priority is to stop activity and reduce myocardial oxygen demand before further diagnostics.

B. Have the client stop walking and sit down: Angina is often triggered by physical exertion. Stopping activity and sitting down reduces oxygen demand on the heart, alleviates symptoms, and prevents further ischemia. This is the most immediate and essential first action.

C. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve anginal pain by dilating coronary arteries, but it should be given after the client has stopped activity and rested. Administering it while the client is still active may not be effective or safe.

D. Measure the client's vital signs: While vital signs are important for assessing the client’s current status, the priority is to stop exertion, which is likely contributing to myocardial oxygen imbalance. Assessment follows immediate symptom relief measures.

Rationale:

A. Encourage the client to discuss feelings of new eating patterns: This requires therapeutic communication and assessment skills, which are beyond the scope of assistive personnel. Such discussions should be initiated and guided by the nurse or mental health professionals.

B. Discuss measures to assist the client to develop a positive body image: Promoting positive self-image involves complex therapeutic techniques and individualized planning, which must be performed by licensed staff, not delegated to assistive personnel.

C. Consult the dietitian to determine the client's caloric intake: Contacting other members of the healthcare team for clinical collaboration is the nurse’s responsibility. This involves interpretation of data and coordination of care, which cannot be delegated.

D. Identify thoughts that reinforce disordered eating patterns: Recognizing cognitive distortions requires clinical judgment and is a core part of therapeutic nursing or psychological care. It cannot be delegated to assistive personnel.

E. Observe the client during meals: Assistive personnel can monitor the client while eating to help prevent purging behaviors. Meal observation is a standard component of bulimia nervosa management and does not require clinical decision-making, making it appropriate for delegation.

F. Accompany the client to the restroom following meals: Clients with bulimia may attempt to purge after eating, so monitoring them post-meal is critical. This task involves supervision rather than evaluation and is suitable for assistive personnel under nursing guidance.

G. Use cognitive behavioral techniques to address the client's behavior: CBT strategies are specialized interventions requiring advanced training, typically carried out by licensed nurses, therapists, or psychologists. These are not within the role of assistive personnel.

H. Check the client’s vital signs: Vital signs collection is a routine task that falls within the scope of assistive personnel when the client is stable. The nurse remains responsible for interpreting any abnormalities.

I. Perform daily weights: Weighing the client is a routine, objective measurement that does not require nursing judgment. It is appropriate to delegate this task as long as the AP follows the nurse’s instructions on timing and procedure.