A nurse is assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

Choice A reason: Relapse is an Indication that You Are Not Taking Your Medications Properly

This statement is not entirely accurate. While non-adherence to medication can be a factor in relapse, it is not the only cause. Schizophrenia is a complex condition, and relapses can occur even when medications are taken as prescribed. Stress, changes in routine, and other factors can also contribute to a relapse.

Choice B reason: You Should Keep Your Provider’s and Therapist’s Number with You

This statement indicates an understanding of the importance of having immediate access to professional help. Keeping contact information for healthcare providers and therapists readily available ensures that the client can quickly reach out for support if they notice early signs of relapse. This proactive approach can help manage symptoms before they escalate.

Choice C reason: Taking an Additional Dose of Medication is Appropriate as Soon as Signs of Relapse Appear

This statement is incorrect. Clients should not adjust their medication dosage without consulting their healthcare provider. Taking an additional dose can lead to adverse effects and may not address the underlying issue. It is crucial to follow the prescribed treatment plan and seek professional advice if symptoms worsen.

Choice D reason: You Should Be Aware that Excessive Sleeping is an Early Sign of Relapse

Excessive sleeping is not typically an early sign of schizophrenia relapse. Common early warning signs include insomnia, social withdrawal, difficulty concentrating, and increased paranoia. While changes in sleep patterns can be a symptom, it is more important to recognize the specific signs that have previously indicated a relapse for the individual.

Choice A reason: Plan of care changes for the upcoming shift

Plan of care changes for the upcoming shift are typically included in the “Recommendation” segment of SBAR. This section focuses on what actions need to be taken next, including any changes in the care plan that the oncoming nurse should be aware of. It ensures that the incoming nurse knows what to expect and what specific tasks or interventions are required during their shift.

Choice B reason: Intracranial pressure readings

Intracranial pressure (ICP) readings are crucial for monitoring a client with a traumatic brain injury. However, these readings are more appropriately included in the “Assessment” segment of SBAR. The assessment section provides an analysis of the client’s current condition, including vital signs, lab results, and other critical data. This information helps the oncoming nurse understand the client’s current status and any immediate concerns.

Choice C reason: Glasgow results

The Glasgow Coma Scale (GCS) results are used to assess the level of consciousness in clients with brain injuries. These results should also be included in the “Assessment” segment of SBAR. The GCS score provides valuable information about the client’s neurological status and helps guide clinical decisions. Including this information in the assessment ensures that the oncoming nurse has a clear understanding of the client’s current condition.

Choice D reason: Code status

Code status is a critical piece of information that should be included in the “Background” segment of SBAR. The background section provides relevant clinical history and context for the current situation. Knowing the client’s code status (e.g., full code, do not resuscitate) is essential for making informed decisions about their care, especially in emergency situations. Including this information in the background ensures that the oncoming nurse is aware of the client’s preferences and legal directives.