A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply)

Choice A reason: Discussing a spiritual counselor addresses potential comfort but assumes spiritual needs without assessment, not an immediate priority. Complicated grieving requires normalizing emotions first to build trust and coping. This intervention is supportive but secondary to addressing current feelings, so it’s not the top focus now.

Choice B reason: Identifying the grief stage (e.g., Kubler-Ross) provides insight but isn’t urgent in complicated grief, where emotions like anger dominate. It’s a tool for understanding, not immediate relief. Normalizing feelings takes precedence to prevent escalation, making this less critical initially.

Choice C reason: Informing the client anger is expected validates their emotions in complicated grief, a priority to reduce isolation and guilt after a child’s death. This normalization prevents worsening distress, aligning with safety and emotional stabilization, the first step in care, making it the correct choice.

Choice D reason: Encouraging physical activity promotes health but doesn’t address acute emotional pain in complicated grief, a secondary coping strategy. Anger and loss need validation before behavioral interventions. This action lacks immediacy for the client’s current state, so it’s not the priority.

Choice A reason: Assistive personnel can engage in non-therapeutic, supportive tasks like solitary activities (e.g., puzzles) with a manic client, aiding distraction within their scope. This doesn’t require clinical judgment or education, fitting their role. It frees the nurse for skilled tasks, making it an appropriate delegation choice.

Choice B reason: Discussing medication adverse effects requires nursing knowledge of pharmacology and client response, beyond assistive personnel’s training. It involves assessment and education, reserved for licensed staff. Delegating this risks misinformation and safety, so it’s outside their scope and incorrect.

Choice C reason: Witnessing informed consent demands understanding legal and clinical implications, a nursing responsibility, not assistive personnel’s role. They lack authority to verify comprehension or voluntariness. This task can’t be delegated, as it’s a professional duty, making it unsuitable here.

Choice D reason: Explaining light therapy benefits involves teaching about treatment effects, requiring nursing expertise in depression management. Assistive personnel aren’t trained for such education, risking inaccurate delivery. This remains a nurse’s role, not delegable, so it’s not the correct choice.