A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make?

Choice A reason: Plan a plan of care for a client when postoperative from an appendectomy

Planning a plan of care for a client, especially postoperatively, is a complex task that requires comprehensive assessment and critical thinking skills. This responsibility typically falls within the scope of practice of a registered nurse (RN) rather than an LPN. The RN is trained to develop individualized care plans based on a thorough assessment of the client’s condition, medical history, and specific needs. This ensures that the care plan is holistic and addresses all aspects of the client’s recovery.

Choice B reason: Provide discharge instructions to a confused client’s spouse

Providing discharge instructions, particularly to a confused client’s spouse, involves detailed communication and education. This task is generally performed by an RN, who has the expertise to ensure that the instructions are clear, comprehensive, and tailored to the client’s specific needs. The RN can also assess the spouse’s understanding and provide additional clarification as needed. This ensures that the client receives appropriate care at home and reduces the risk of complications.

Choice C reason: Administer a tap-water enema to a client who is preoperative

Administering a tap-water enema is a task that can be safely delegated to an LPN. LPNs are trained to perform routine procedures such as enemas, which do not require the advanced assessment skills of an RN. This task involves following established protocols and ensuring the client’s comfort and safety during the procedure. By delegating this task to an LPN, the RN can focus on more complex aspects of client care.

Choice D reason: Clean vital signs from a client who is 6 hours postoperative

Obtaining and recording vital signs is a fundamental skill within the LPN’s scope of practice, as it involves routine data collection without interpretation or care‑planning decisions.

Choice E reason: Catheterize a client who has not voided in 8 hours

Catheterization is a procedure that LPNs are trained to perform. This task involves inserting a catheter to relieve urinary retention, which can be a common issue in postoperative clients. LPNs can perform this procedure safely and effectively, following established protocols to minimize the risk of infection and ensure the client’s comfort. Delegating this task to an LPN allows the RN to focus on other critical aspects of client care.

Choice A reason:

Pruritus: Pruritus, or itching, can be uncomfortable and may indicate underlying conditions such as dry skin, allergies, or liver disease. However, it is not typically an immediate threat to health and can often be managed with topical treatments or antihistamines.

Choice B reason:

Swollen gums: Swollen gums can be a sign of gingivitis or other dental issues. While important to address, it is not usually an urgent condition unless it is causing severe pain or infection. Dental problems can lead to complications if untreated, but they are generally not life-threatening.

Choice C reason:

Dysphagia: Dysphagia, or difficulty swallowing, is a serious condition that can lead to aspiration, malnutrition, and dehydration. It can be caused by neurological disorders, structural abnormalities, or other medical conditions. Because it can directly impact the client’s ability to eat and drink safely, it is a priority for immediate assessment and intervention.

Choice D reason:

Urinary hesitancy: Urinary hesitancy, or difficulty starting urination, can be a symptom of benign prostatic hyperplasia (BPH) or other urinary tract issues. While it can cause discomfort and lead to urinary retention, it is generally not as immediately life-threatening as dysphagia.