While performing hygiene care for a client, a nurse notices a frayed electrical cord on the client’s electronic blood pressure monitor.
Which of the following actions should the nurse take first?

The correct answer is choice D. “I’ll think about my grandfather’s farm to reduce pain.” This statement indicates an understanding of guided imagery, which is a relaxation technique that aims to help lower the levels of stress hormones and pain perception by imagining a scene that involves each of the senses and positive emotions.

Guided imagery can help to distract from pain signals and reduce anxiety, which can also contribute to pain.

Choice A is wrong because it does not involve creating a specific imagined reality, but rather noticing the sensation of muscle tension, which may increase awareness of pain.

Choice B is wrong because it does not involve using all of the senses and emotions, but rather listening to music, which may be relaxing but not as effective as guided imagery for pain relief.

Choice C is wrong because it does not involve imagining a scene, but rather using focused breathing to control pain, which is another relaxation technique but not guided imagery.

- When coordinating the care of a group of clients with assistive personnel (AP), it's important to delegate tasks appropriately based on the AP's scope of practice and training. Here are the tasks that can be assigned to the AP:

Measure the intake and output of a client who has received furosemide: This task involves recording fluid intake and output, which is typically within the scope of practice for an AP, as long as they have been trained in the proper procedure and documentation.

Check a client’s peripheral IV site for redness or swelling: This task involves basic assessment and can be assigned to an AP, as long as they are familiar with the signs of potential complications related to IV sites and have been trained in the facility's protocol for reporting any issues.

Reinforcing teaching with a client about crutch-gait walking: Education and reinforcement of information provided by healthcare professionals can often be delegated to APs, especially if they have received training on the specific topic. However, it's important to ensure that the AP is knowledgeable about crutch-gait walking and the information they are reinforcing.

The task related to assessing pain (e.g., assessing the pain level of a client who has received acetaminophen) should generally be performed by a licensed healthcare provider, such as a nurse. Assessment of pain requires a deeper understanding of the client's pain experience and may involve making clinical decisions related to pain management.