Level: Clinical
Difficulty: Medium
Subtopic: Elimination
NCLEX: A 76-year-old client in a long-term care facility is being evaluated for nursing care related to elimination. Ass…
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 elimination. Assessment data include the client reports no sleep and increasing agitation overnight. 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.