Level: Clinical
Difficulty: Medium
Subtopic: Mobility and positioning
NCLEX: A 76-year-old client in a long-term care facility is being evaluated for nursing care related to mobility and pos…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 76-year-old client in a long-term care facility is being evaluated for nursing care related to mobility and positioning. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Which communication to the oncoming nurse or provider is most appropriate?
Question
A. "The client is doing fine; no issues to report."
B. Vague statements without measurable assessment data.
C. Blaming the client for nonadherence instead of stating facts.
D. SBAR format with specific objective findings, current status, and a clear recommendation.
B. Vague statements without measurable assessment data.
C. Blaming the client for nonadherence instead of stating facts.
D. SBAR format with specific objective findings, current status, and a clear recommendation.
Rationale
Correct answer: D. SBAR format with specific objective findings, current status, and a clear recommendation.
Rationale: Handoff and escalation require concise, objective communication such as SBAR with current assessment data.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Handoff and escalation require concise, objective communication such as SBAR with current assessment data.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.