Level: Foundational
Difficulty: Easy
Subtopic: Therapeutic communication
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for anxiety about hospitalization. Assessm…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for anxiety about hospitalization. Assessment data include the client is pacing aggressively, clenching fists, and refusing to sit. Which communication to the oncoming nurse or provider is most appropriate?
Question
A. SBAR format with specific objective findings, current status, and a clear recommendation.
B. "The client is doing fine; no issues to report."
C. Vague statements without measurable assessment data.
D. Blaming the client for nonadherence instead of stating facts.
B. "The client is doing fine; no issues to report."
C. Vague statements without measurable assessment data.
D. Blaming the client for nonadherence instead of stating facts.
Rationale
Correct answer: A. 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.