The nurse is continuing to care for the child.

Exhibits

Select the 3 priority actions that the nurse should take.

Rationale:

A. A client who moved to an apartment located on higher ground than her previous home: Relocating for safety is a rational coping mechanism and does not, on its own, indicate PTSD. This action reflects adaptation rather than signs of trauma-related distress.

B. A client who has frequent nightmares about the hurricane: Recurrent nightmares related to the traumatic event are a hallmark symptom of PTSD and suggest that the client is experiencing persistent re-experiencing of the trauma.

C. A client who expresses a realization that life will not return to the way it was before the hurricane: This statement reflects acceptance and realistic processing of the event, not necessarily indicative of emotional distress or dysfunction associated with PTSD.

D. A client who describes having persistent feelings of anger about the hurricane: Chronic irritability or anger following trauma is a recognized symptom of PTSD and may indicate the client is struggling with emotional regulation due to unresolved trauma.

E. A client who describes feeling disconnected from those around him following the hurricane: Emotional numbing or detachment from others is a common symptom of PTSD, often associated with difficulty in re-establishing interpersonal connections after trauma.

Rationale:

A. Encourage the client to discuss feelings of new eating patterns: This requires therapeutic communication and assessment skills, which are beyond the scope of assistive personnel. Such discussions should be initiated and guided by the nurse or mental health professionals.

B. Discuss measures to assist the client to develop a positive body image: Promoting positive self-image involves complex therapeutic techniques and individualized planning, which must be performed by licensed staff, not delegated to assistive personnel.

C. Consult the dietitian to determine the client's caloric intake: Contacting other members of the healthcare team for clinical collaboration is the nurse’s responsibility. This involves interpretation of data and coordination of care, which cannot be delegated.

D. Identify thoughts that reinforce disordered eating patterns: Recognizing cognitive distortions requires clinical judgment and is a core part of therapeutic nursing or psychological care. It cannot be delegated to assistive personnel.

E. Observe the client during meals: Assistive personnel can monitor the client while eating to help prevent purging behaviors. Meal observation is a standard component of bulimia nervosa management and does not require clinical decision-making, making it appropriate for delegation.

F. Accompany the client to the restroom following meals: Clients with bulimia may attempt to purge after eating, so monitoring them post-meal is critical. This task involves supervision rather than evaluation and is suitable for assistive personnel under nursing guidance.

G. Use cognitive behavioral techniques to address the client's behavior: CBT strategies are specialized interventions requiring advanced training, typically carried out by licensed nurses, therapists, or psychologists. These are not within the role of assistive personnel.

H. Check the client’s vital signs: Vital signs collection is a routine task that falls within the scope of assistive personnel when the client is stable. The nurse remains responsible for interpreting any abnormalities.

I. Perform daily weights: Weighing the client is a routine, objective measurement that does not require nursing judgment. It is appropriate to delegate this task as long as the AP follows the nurse’s instructions on timing and procedure.