A nurse is preparing a client for a cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take?

Choice A Reason:
A toddler who cries whenever their parent enters the examination room is incorrect. Toddlers may exhibit separation anxiety or fear of medical procedures, which is a common behavior in this age group.
Choice B Reason:
An adolescent who was admitted and refuses to speak to their parents is incorrect. Adolescents may exhibit behaviors such as withdrawal or reluctance to communicate with parents due to developmental changes, stress, or other factors unrelated to maltreatment.
Choice C Reason:
A preschooler who was previously toilet trained and now requires diapers in the hospital is incorrect. Regression in toileting skills is common in preschoolers during times of stress or illness, such as hospitalization. It does not necessarily indicate maltreatment but may be a response to the unfamiliar environment or medical condition.
Choice D Reason:
A school-age child who has several abrasions on their lower legs is correct. Abrasions on a school-age child's lower legs could potentially indicate physical abuse or neglect, especially if they are unexplained or inconsistent with the child's reported activities. Reporting such findings for further investigation is essential to ensure the safety and well-being of the child.

Choice A Reason:
Demonstrating the proper client transfer technique for the AP, could be beneficial after ensuring the immediate safety of the client. However, providing immediate assistance to the client is the priority.
Choice B Reason:
Instructing the AP to request assistance when unsure about a task, is important for promoting a culture of safety and collaboration. However, in this scenario, the immediate focus is on assisting the client.
Choice C Reason:
Referring the AP to the facility procedure manual, may be helpful for providing additional guidance and education on proper techniques. However, in the moment, the nurse manager should prioritize immediate action to assist the client.
Choice D Reason:
Helping the AP assist the client with the transfer is correct. When a nurse manager observes an assistive personnel (AP) incorrectly performing a task such as transferring a client, the first priority is ensuring the safety and well-being of the client. Therefore, the nurse manager should intervene immediately to provide assistance and ensure that the client is transferred safely.