A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following client care tasks is within the scope of practice for the AP?

Rationale for correct choices:

• Skin turgor: Poor skin turgor indicates dehydration, which can lead to electrolyte imbalances, hypotension, and renal complications. Immediate assessment and fluid management are necessary to prevent further physiological deterioration.
• Heart rate: A heart rate of 120/min is tachycardic. This can be caused by dehydration, stimulant effects of mania, or other underlying medical issues. It requires prompt monitoring and intervention to prevent cardiovascular compromise.
• Sleep pattern: The client has not slept for 2 days, which increases the risk for physical exhaustion, worsening psychiatric symptoms, and impaired judgment. Sleep deprivation in the context of mania requires immediate attention to stabilize the client.
• Hallucinations: The client reports listening to unseen others, indicating auditory hallucinations. This can pose a risk for self-harm or unsafe behaviors, and immediate psychiatric assessment and intervention are warranted.

Rationale for incorrect choice:

• Hygiene: While the client’s hair and clothing are unclean, indicating self-care deficits, this is not an immediate threat to physiological stability. It is important for overall care planning but does not require urgent intervention compared to dehydration, tachycardia, sleep deprivation, or hallucinations.

Rationale:

A. "I don't think you will benefit from reviewing your therapist's notes right now.": This statement dismisses the client’s request without addressing legal and policy guidelines regarding access to records. It also inappropriately assumes the client’s capacity to benefit from the information.

B. "Are you not happy with your treatment?": This redirects the conversation away from the request and implies dissatisfaction, which can create defensiveness. It does not provide the client with accurate information about their right to access medical records.

C. "Why are you interested in seeing your therapist's notes?": Asking “why” can sound confrontational and does not answer the client’s question. The focus should be on explaining what parts of the record can be shared, according to policy and law.

D. "We can provide a copy of your records, but the therapist's notes are not included.": Psychotherapy notes are excluded from standard medical record disclosures under HIPAA, as they are kept separate to protect sensitive details.