A nurse is assessing a client’s understanding of their medication regimen. The client nods in agreement but does not respond verbally. What is the nurse’s best action?

Choice A rationale
“I can see this is very difficult for you.”. This response is appropriate as it acknowledges the client’s emotions and provides validation. It demonstrates empathy and encourages the client to express their feelings, which is essential in therapeutic communication.
Choice B rationale
“Please don’t cry, it’s not good for you.”. This response is inappropriate as it dismisses the client’s emotions and may make them feel invalidated. Crying is a natural response to emotional distress, and the nurse should support the client in expressing their feelings.
Choice C rationale
“Why are you crying?” This response is also inappropriate as it may come across as judgmental or dismissive. It does not provide the support and empathy the client needs during a difficult moment.
Choice D rationale
“Let’s move on to a different topic to distract you.”. This response is not appropriate as it avoids addressing the client’s emotions and may make the client feel that their feelings are not important. The nurse should focus on supporting the client through their emotional experience.

Choice A rationale
This statement does not provide a recommendation for the next steps in the patient’s care. The R step in SBAR stands for Recommendation, which involves suggesting what should be done to address the situation. Stating that there are no provider’s prescriptions available does not fulfill this requirement.
Choice B rationale
This statement is more appropriate for the Assessment step, where the nurse describes the patient’s current condition. The R step should focus on what actions need to be taken next, not just the patient’s current state.
Choice C rationale
This statement is correct because it provides a clear recommendation for the next steps in the patient’s care. The R step in SBAR is meant to suggest what should be done to address the situation, and reviewing the client’s orders is a specific action that can be taken.
Choice D rationale
This statement is more appropriate for the Situation or Background steps, where the nurse describes what has happened to the patient. The R step should focus on what actions need to be taken next, not just the patient’s history.