A nurse manager is teaching a newly licensed nurse about pain management for an older adult client. Which of the following statements by the nurse indicates an understanding of the teaching?

Rationale:

A. Place the client upright on a donut-shaped cushion: Donut-shaped cushions are not recommended because they create uneven pressure distribution, which can worsen ischemia around pressure points rather than relieve it, potentially delaying healing.

B. Teach the client to shift his weight every 15 min while sitting: Frequent weight shifting relieves pressure on the ischial area and promotes circulation, helping to prevent progression of a stage 1 pressure injury. This intervention supports client independence and tissue integrity.

C. Assess pressure points every 24 hr: Pressure points should be assessed more frequently than once daily, especially in high-risk clients. Routine skin assessments at least once per shift are critical for early detection of pressure injury progression.

D. Turn and reposition the client every 3 hr while in bed: The standard recommendation is to reposition immobile clients at least every 2 hours in bed to redistribute pressure and reduce the risk of further skin breakdown. Extending intervals increases risk of injury.

Rationale:

A. Encourage the client to discuss feelings of new eating patterns: This requires therapeutic communication and assessment skills, which are beyond the scope of assistive personnel. Such discussions should be initiated and guided by the nurse or mental health professionals.

B. Discuss measures to assist the client to develop a positive body image: Promoting positive self-image involves complex therapeutic techniques and individualized planning, which must be performed by licensed staff, not delegated to assistive personnel.

C. Consult the dietitian to determine the client's caloric intake: Contacting other members of the healthcare team for clinical collaboration is the nurse’s responsibility. This involves interpretation of data and coordination of care, which cannot be delegated.

D. Identify thoughts that reinforce disordered eating patterns: Recognizing cognitive distortions requires clinical judgment and is a core part of therapeutic nursing or psychological care. It cannot be delegated to assistive personnel.

E. Observe the client during meals: Assistive personnel can monitor the client while eating to help prevent purging behaviors. Meal observation is a standard component of bulimia nervosa management and does not require clinical decision-making, making it appropriate for delegation.

F. Accompany the client to the restroom following meals: Clients with bulimia may attempt to purge after eating, so monitoring them post-meal is critical. This task involves supervision rather than evaluation and is suitable for assistive personnel under nursing guidance.

G. Use cognitive behavioral techniques to address the client's behavior: CBT strategies are specialized interventions requiring advanced training, typically carried out by licensed nurses, therapists, or psychologists. These are not within the role of assistive personnel.

H. Check the client’s vital signs: Vital signs collection is a routine task that falls within the scope of assistive personnel when the client is stable. The nurse remains responsible for interpreting any abnormalities.

I. Perform daily weights: Weighing the client is a routine, objective measurement that does not require nursing judgment. It is appropriate to delegate this task as long as the AP follows the nurse’s instructions on timing and procedure.