A. "The client works in the hospital radiology department": This information is irrelevant to the client’s current health status and does not imply a need for total care by the nurse.

B. "The client discussed having prior thoughts of suicide": While suicidal ideation is serious and requires careful monitoring and assessment, this information alone does not necessarily indicate that the nurse must assume total care. A nurse would still delegate non-critical tasks to the AP, but constant monitoring and appropriate interventions would still be the nurse’s responsibility.

C. "The client's blood pressure and pulse have been fluctuating throughout the day": Fluctuating vital signs, especially blood pressure and pulse, can indicate an unstable condition that may require immediate attention and careful monitoring. This scenario suggests that the client’s condition may be critical and requires ongoing assessment and evaluation by the nurse, rather than simply delegating tasks like monitoring vital signs to assistive personnel (AP). The nurse needs to assess the situation thoroughly, interpret the fluctuations, and adjust the care plan accordingly.

D. "The client's family members have been present most of the day": Family presence alone does not impact the need for total care by the nurse. It is important for the nurse to communicate with the family, but this statement does not indicate the need for the nurse to assume total care over other team members.

Provide continuous monitoring of this client: Continuous monitoring is essential to ensure the client's safety while in seclusion, particularly given their agitated and potentially harmful behavior.

Obtain provider prescription for seclusion or restraints: It's necessary to ensure that the use of seclusion is appropriately authorized and documented, following the facility's protocol and legal requirements.

Rationale:

A. Reporting the observation to the nurse caring for that client is important but not the immediate priority.

B. Informing the nursing supervisor is necessary but should be done after assessing the situation directly.

C. Approaching the man and asking why he is making copies is the most immediate and direct action. It allows the nurse to assess the situation and determine if the man has legitimate access to the client's medical record or if further action is needed.

D. Notifying hospital security may be necessary if the man’s actions are unauthorized, but the first step is to gather more information.

Rationale:

A. Check the position of a client in soft wrist restraints is appropriate for an AP as it involves routine monitoring and ensuring the client's safety.

B. Accompany a client who has depression to occupational therapy is a task that can be assigned to an AP, as it involves providing support and ensuring the client's safe arrival to therapy.

C. Set limits with a client who has mania is not appropriate for an AP, as this involves therapeutic communication and behavior management, which requires nursing judgment.

D. Sit with a client who has alcohol use disorder and whose last drink was five days ago can be assigned to an AP as it involves providing a supportive presence and monitoring, but the nurse should assess for withdrawal symptoms.

E. Assess a client who has hypomania for exhaustion is a nursing responsibility that involves evaluation and judgment, making it inappropriate to delegate to an AP.

Rationale:

A. Ambulate an older adult client who has hypertension is a task that an AP can perform, provided the client is stable and has been assessed by the nurse.

B. Provide discharge instructions for a client who has a new skin graft is a task that requires nursing judgment and cannot be delegated to an AP.

C. Check a blood product with another nurse prior to administration is a nursing responsibility that requires verification by licensed personnel and cannot be delegated to an AP.

D. Weigh a client who has heart failure is appropriate for an AP, as it involves routine measurement that can be delegated.

E. Perform an admission assessment on a client is a nursing responsibility and cannot be delegated to an AP.

Rationale:

A. Dilated pupils are typically associated with stimulant use, not opioids.

B. Euphoria is a common effect of opioid use and can indicate misuse or diversion of these medications.

C. Rhinorrhea is usually associated with withdrawal from opioids rather than their use.

D. Hallucinations can occur with certain drugs but are less commonly associated with opioid use compared to euphoria.

Rationale:

A. The client should sign the informed consent if they are alert, oriented, and capable of making decisions. The client's ability to understand the procedure and its implications is key to valid informed consent.

B. The client's son, who has a durable power of attorney would only sign the consent if the client were not competent or unable to understand the procedure, which is not the case here.

C. The client's partner may be involved in the decision-making process but does not have the legal authority to sign the consent unless designated as a legal representative.

D. The client's daughter, who is the primary caregiver would also not have the legal authority to sign the consent unless she holds a durable power of attorney or the client is deemed incapable of giving consent.

A. While the client's temperature is not extremely high, it is elevated and persistent. Requesting an antipyretic or further evaluation may be warranted to prevent potential complications.

B. Insertion of NG tube for decompression is not necessary as the client is passing flatus and has bowel sounds in all quadrants, indicating normal gastrointestinal function.

C. Oxygen 2 to 4 L/min via nasal cannula is not necessary since the client's SpO2 levels are within normal range on room air.

D. The client's urinary output is adequate (400 mL over 6 hours), so a catheter is not required at this time.

E. The lack of drainage from the wound drain could indicate a problem that requires immediate attention. This could prevent complications like infection or fluid accumulation.

Rationale:

A. A client who has Guillain-Barre syndrome requires close monitoring and specialized care due to progressive weakness and potential respiratory issues. This client's care may involve more complex needs that are beyond the AP's scope.

B. A client who has a lumbosacral spinal tumor is likely to have fewer immediate needs related to eating assistance, making this task appropriate to delegate to the AP. The client’s primary concern may be mobility or pain management, but meal assistance is a routine task.

C. A client who has systemic sclerosis may have issues with gastrointestinal motility and swallowing, requiring more careful feeding assistance and monitoring, which should be performed by the nurse.

D. A client who has amyotrophic lateral sclerosis (ALS) requires specialized care for swallowing difficulties and respiratory issues, making it inappropriate to delegate meal assistance to the AP.

Rationale:

A. A young adult client admitted for acute glomerulonephritis following a viral infection does not indicate a mandatory report situation.

B. A dependent adult admitted for the treatment of a spiral fracture suggests potential abuse or neglect. As mandated reporters, nurses are required to report suspicions of abuse or neglect to the appropriate authorities.

C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse does not necessarily require mandatory reporting unless there is evidence of abuse or harm that needs to be reported.

D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment may raise concerns about the minor's capacity to make decisions, but it does not automatically necessitate reporting to an outside agency.