A nurse is observing an assistive personnel (AP) apply a belt restraint on a client. Which of the following actions by the AP requires intervention by the nurse?

A) Establishing the priorities of client care:

Establishing priorities of client care typically occurs during the planning phase of the nursing process, not during implementation. During the planning phase, the nurse identifies the most urgent client needs based on assessments and formulates a plan of action to address those needs.

B) Reinforcing teaching about the client's diagnosis:

Reinforcing teaching about the client's diagnosis is an appropriate activity during the implementation phase of the nursing process. Implementation involves carrying out the planned interventions, which may include educating the client about their diagnosis, treatment plan, and self-care strategies. Reinforcing teaching ensures that the client understands their condition and how to manage it effectively.

C) Asking the client about the presence of pain:

Assessing the client for pain is typically part of the assessment phase of the nursing process, not the implementation phase. During assessment, the nurse gathers data about the client's pain experience, including location, intensity, quality, and factors that alleviate or exacerbate pain.

D) Comparing the client's current laboratory values to previous results:

Comparing laboratory values is a component of data interpretation and analysis, which occurs primarily during the evaluation phase of the nursing process. While the nurse may review laboratory values during implementation to monitor the client's response to interventions, comparing current values to previous results is more closely associated with evaluating the effectiveness of care provided.

A) "I will contact the provider to let her know":

This response acknowledges the client's uncertainty about the procedure and indicates the nurse's commitment to address the client's concerns promptly by involving the healthcare provider. Contacting the provider allows for further discussion of the client's decision and consideration of any alternatives or additional information needed to support the client's choice.

B) "You should discuss your concerns with your family":

While involving family members in decision-making can be beneficial, especially for emotional support, the client's decision about the procedure is ultimately theirs to make. Encouraging discussion with family members without addressing the client's immediate concerns may not effectively address the situation.

C) "This procedure is perfectly safe":

Asserting the safety of the procedure without addressing the client's uncertainties or reasons for hesitation may not adequately address the client's concerns. It's essential to acknowledge and explore the client's apprehensions rather than dismissing them outright.

D) "Why are you changing your mind about the procedure?":

This response may come across as confrontational and may put the client on the defensive. It's important to approach the situation with empathy and support, allowing the client to express their concerns openly without feeling judged or pressured.