The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)

Choice A reason: A 16-year-old client diagnosed with major depression who refuses to participate in group does not require the nurse's immediate attention. Depression is a mood disorder that causes persistent feelings of sadness, hopelessness, and loss of interest. Refusing to participate in group may indicate low motivation, social withdrawal, or poor self-esteem, which are common symptoms of depression. The nurse should respect the client's preference and offer alternative activities or individual therapy.

Choice B reason:This client requires immediate intervention because pacing can be a sign of agitation, restlessness, or escalating mania. Clients with bipolar disorder in a manic phase may exhibit increased energy, impulsivity, irritability, and even aggression. If not addressed promptly, this behavior could escalate to disruptive outbursts, impulsive actions, or even violence toward themselves or others. The nurse should intervene by using calm communication, redirection, and possibly medication if prescribed to help de-escalate the situation and ensure safety.

Choice Creason:This scenario involves peer conflict, which is important to address, but it does not necessarily indicate an immediate risk of harm. Clients with antisocial behavior often engage in conflict due to manipulative or confrontational tendencies, but being yelled at does not mean they are in immediate danger. The nurse should monitor the situation and intervene to prevent escalation, but other safety concerns take priority.

Choice D reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack does not require the nurse's immediate attention. Anorexia nervosa is an eating disorder that causes extreme restriction of food intake and fear of weight gain. Refusing to eat the evening snack may indicate distorted body image, dietary rules, or anxiety, which are common factors of anorexia nervosa. The nurse should encourage the client to eat and provide support and education.

A: An adolescent with multiple contusions due to a fall that occurred 2 days ago can be managed by the PN as the condition is stable and does not require the advanced skills of an RN.
B: A 75-year-old client with renal calculi who requires urine straining can also be assigned to the PN because urine straining is a task within the PN's scope of practice.
C: A 30-year-old depressed client who admits to suicide ideation requires the expertise of an RN due to the need for continuous assessment, potential for crisis intervention, and the complexity of care needed.
D: A 64-year-old client who had a total hip replacement the previous day would typically be stable post-operation and could be managed by the PN, with the RN available for any complications that may arise.