Level: Advanced
Difficulty: Hard
Subtopic: Musculoskeletal assessment
NCLEX: A 74-year-old client on a medical-surgical unit is being evaluated for musculoskeletal assessment during hospital…
Health assessment Reduction of Risk Potential
Case Study
A 74-year-old client on a medical-surgical unit is being evaluated for musculoskeletal assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. 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. SBAR format with specific objective findings, current status, and a clear recommendation.
D. Blaming the client for nonadherence instead of stating facts.
B. Vague statements without measurable assessment data.
C. SBAR format with specific objective findings, current status, and a clear recommendation.
D. Blaming the client for nonadherence instead of stating facts.
Rationale
Correct answer: C. 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.