A nurse is planning care for a client who is 6 hr. postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's plan of care?

Choice A Reason:

Abnormal Involuntary Movement Scale is correct. The Abnormal Involuntary Movement Scale (AIMS) is a standardized tool used to assess and identify tardive dyskinesia, a side effect of antipsychotic medications. Tardive dyskinesia involves involuntary, repetitive movements, typically involving the face, mouth, and sometimes other body parts. Regular monitoring using the AIMS helps healthcare providers detect and evaluate the severity of these abnormal movements, allowing for appropriate management and intervention as needed.

Choice B Reason:

Mental Status Examination (MSE) is incorrect. The MSE is a comprehensive assessment of a person's mental state and cognitive function. While it is valuable for assessing a person's overall mental health and cognitive status, it is not specific for identifying tardive dyskinesia, which is a specific movement disorder.

Choice C Reason:

Brief Psychiatric Rating Scale (BPRS) is incorrect. The BPRS is a tool used to assess the severity of psychiatric symptoms and their changes over time. It is not specific for identifying the physical movements associated with tardive dyskinesia.

Choice D is incorrect:

Patient Health Questionnaire (PHQ) is incorrect. The PHQ is a self-report tool used to screen for symptoms of depression and anxiety. It is not designed for identifying movement disorders like tardive dyskinesia, which are characterized by abnormal physical movements.

Choice A Reason:

Transfer a client who is receiving radiation therapy to radiology is not appropriate .Transferring a client receiving radiation therapy may involve specific safety considerations and precautions that should be performed by a healthcare professional with appropriate training.

Choice B Reason:

Measure vital signs for a client who requires contact precautions is appropriate. Measuring vital signs, such as taking temperature, blood pressure, heart rate, and respiratory rate, is a routine task that can be safely delegated to an AP.

Choice C Reason:

Record urine output for a client who has a suprapubic catheter is appropriate. Recording urine output is a straightforward task that can be delegated to an AP, provided they are trained in the proper technique for measuring and documenting urine output

Choice D Reason:

Plan care for a client who has dysphagia is incorrect. Planning care for a client with dysphagia involves assessment, evaluation, and coordination of care, which require the expertise of a licensed nurse or healthcare provider.