Level: Advanced
Difficulty: Hard
Subtopic: Trend recognition
NCLEX: A client in an unfolding case study is being evaluated for nursing care related to trend recognition. Assessment…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
A client in an unfolding case study is being evaluated for nursing care related to trend recognition. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. 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.