A nurse in the emergency department is caring for a client.

Exhibits

The nurse reviews the client’s medical record. Select the 4 actions the nurse should take.

A. Sneezing is a mild symptom unrelated to acute chest syndrome.

B. Substernal retractions indicate respiratory distress, a hallmark of acute chest syndrome, which is a life-threatening complication of sickle-cell disease caused by sickling in the pulmonary vasculature. This leads to hypoxia, chest pain, fever, and respiratory failure if untreated.

C. Hematuria may occur with sickling in renal capillaries but is not an emergency.

D. A low-grade fever is common in infection or inflammation but does not indicate acute chest syndrome by itself.

A. Perform daily weights: Daily weights are important to monitor progress and detect fluid or nutritional changes. This routine, non-invasive task is appropriate for delegation to assistive personnel (AP) under nurse supervision.

B. Identify thoughts that reinforce disordered eating patterns: Requires therapeutic communication and assessment, which are nursing responsibilities. Not appropriate for delegation to AP.

C. Accompany the client to the restroom following meals: Clients with bulimia are at risk of vomiting or purging after eating. Having an AP accompany the client helps prevent self-induced vomiting and ensures compliance with the treatment plan. The AP should report any unusual behavior to the nurse.

D. Observe the client during meals: Monitoring during meals ensures the client eats appropriately and avoids concealing or discarding food. This is a behavioral safety measure that can be delegated, while the nurse focuses on therapeutic interventions.

E. Consult the dietitian to determine the client’s caloric intake: Consulting other team members is a nursing role, involving coordination of interdisciplinary care.

F. Use cognitive behavioral techniques to address the client’s behavior: CBT and psychotherapy require specialized knowledge and are conducted by nurses or mental health professionals, not assistive personnel.

G. Discuss measures to assist the client to develop a positive body image: Involves therapeutic communication and counseling, not within the AP’s scope.

H. Encourage the client to discuss feelings of new eating patterns: Addressing emotions and behavioral change is a therapeutic intervention requiring nursing judgment.

I. Check the client’s vital signs: Vital signs provide data about orthostatic hypotension, dehydration, or arrhythmia risk. The AP can collect this data, while the nurse evaluates and interprets the results.