A nurse is reinforcing instructions about car-seat use with the parents of a newborn who is preparing for discharge. Which of the following Instructions should the nurse include?

Rationale:

A. Reinforce client teaching about walking with crutches: Teaching or reinforcing client education is a nursing responsibility and should not be delegated to assistive personnel. It requires assessment, evaluation, and knowledge of the client's learning needs and physical limitations.

B. Plan care for a client who has dysphagia: Care planning involves critical thinking and individualized assessment, which fall under the registered nurse’s scope of practice. Dysphagia management also requires knowledge of aspiration risk and appropriate interventions.

C. Transfer a client who is receiving radiation therapy to radiology: Transferring stable clients to departments such as radiology is within the scope of assistive personnel, as long as the client does not require specialized monitoring or assessment during the transfer.

D. Record urine output for a client who has a suprapubic catheter: Measuring and documenting urinary output is a routine task that assistive personnel can perform. The catheter type does not affect the ability to carry out this basic observation.

E. Measure vital signs for a client who requires contact precautions: Assistive personnel are trained to take vital signs and follow isolation protocols. Measuring vital signs under contact precautions is appropriate as long as proper PPE and hygiene practices are followed.

Rationale:
• Suicidal ideation: The client has a history of suicidal threats and is currently expressing distress, isolation, and a desire to no longer exist. These are key red flags for suicidal thoughts and require immediate monitoring.

• Hopelessness: Statements like “I wish I weren’t here” and “my life is a mess” indicate a loss of hope about the future. Hopelessness is a strong predictor of suicidal intent in clients with depression.

• Acute stress disorder: This condition involves exposure to a traumatic event within the past month with symptoms like flashbacks or dissociation. The client’s distress stems from life changes, not acute trauma.

• Borderline personality disorder: While this disorder includes unstable relationships and emotional reactivity, there is no history of impulsivity or identity disturbance to support the diagnosis.

• Emotional lability: The client displays a flat affect and tearfulness, not rapid mood shifts. Emotional lability refers to quick and exaggerated changes in emotional expression.

• Hypervigilance: This involves a heightened state of alertness often associated with trauma or PTSD. The client’s behavior is more aligned with withdrawal and depression.