A nurse is working in an urgent care clinic when a client who does not speak the same language arrives with a laceration that will require suturing. Which of the following actions is appropriate for the nurse to take?

A. Document the client's respiratory rate in 1 hr: Measuring and recording vital signs, including respiratory rate, is within the scope of practice for an assistive personnel (AP). After the nurse administers a PRN pain medication, the AP can safely monitor and document routine parameters, providing the nurse with data to evaluate the client’s response.

B. Monitor the client for an allergic reaction for 30 min: Observing for adverse or allergic reactions requires nursing assessment skills, clinical judgment, and the ability to intervene immediately if a severe reaction occurs. This task is outside the AP’s scope of practice.

C. Check the client's response to the medication in 1 hr: Evaluating a client’s pain relief or therapeutic response involves subjective assessment and interpretation, which require nursing judgment. This responsibility cannot be delegated to an AP.

D. Evaluate the client for therapeutic effects in 30 min: Assessing the effectiveness of medication, such as pain relief or sedation, requires clinical judgment and decision-making to determine if further interventions are needed. This is a nursing responsibility and should not be assigned to an AP.

A. Frequently remind the client of the expectations for her behavior: Clients experiencing mania may have impaired judgment, impulsivity, and difficulty focusing. Repeated, calm reminders of behavioral expectations help set limits, maintain safety, and reduce the risk of disruptive or harmful actions while promoting structure in the therapeutic environment.

B. Encourage the client to participate in a group activity in the dayroom: Group activities can be overstimulating for a client in the manic phase, increasing agitation, distractibility, and risk of conflict with others. Individual or low-stimulation interventions are safer and more appropriate during acute mania.

C. Allow the client to pick her own choice of clothing: While autonomy is generally encouraged, a manic client may make choices that are socially inappropriate, unsafe, or erratic. Guiding clothing selections may help maintain dignity and safety without restricting personal expression entirely.

D. Encourage the client to increase physical activity during the day: Although physical activity can be beneficial, clients in a manic state may already have excessive energy and impulsivity. Additional encouragement for activity could exacerbate agitation, increase risk of injury, and worsen overstimulation.