Level: Advanced
Difficulty: Hard
Subtopic: Head and neck assessment
NCLEX: A 66-year-old client in an outpatient clinic is being evaluated for head and neck assessment during hospitalizati…
Health assessment Reduction of Risk Potential
Case Study
A 66-year-old client in an outpatient clinic is being evaluated for head and neck assessment during hospitalization. Assessment data include pressure injury stage 2 noted on the coccyx with unchanged dressing. 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.