A nurse is caring for a child who reports being physically abused by a family member. Which of the following statements should the nurse make?

Explanation:

A. Glasgow coma scale result - This would be included in the assessment segment of SBAR, as it provides a clinical evaluation of the client's current neurological status.

B. History of the injury - The situation segment is used to briefly explain the current situation or the reason for the report. Including the history of the injury provides context about why the client is receiving care.

C. Medication during the next shift - This information is part of the Recommendation segment of SBAR. The nurse should include any upcoming medication administration, changes in medication orders, or specific medications that need to be administered during the next shift.

D. Intracranial pressure readings - This information should be included in the Assessment segment of SBAR. It provides important data about the client's intracranial status, helps monitor for changes or trends, and guides ongoing management and interventions.

Explanation:

A. "I will keep my walker at the end of my bed."

Keeping the walker at the end of the bed is generally a good practice for accessibility and mobility support, especially for clients who use walkers to assist with walking. However, this statement alone does not directly address falls prevention strategies or indicate a comprehensive understanding of home safety measures related to falls.

B. "I will place an area rug at the entry of my bathroom."

Placing an area rug at the entry of the bathroom can actually increase the risk of falls rather than prevent them. Area rugs are common tripping hazards, especially in areas where water or moisture may be present (like bathrooms). This statement indicates a potential misunderstanding of falls prevention strategies because it suggests an action that could contribute to falls rather than prevent them.

C. "I will place a bath seat in my shower to use when I bathe."

This statement demonstrates a clear understanding of falls prevention strategies. Placing a bath seat in the shower is a proactive measure to enhance safety during bathing, as it provides stability and reduces the risk of slipping and falling on wet surfaces. Using assistive devices like a bath seat is recommended for individuals with a history of falls or balance issues.

D. "I will keep the fluorescent ceiling light on in my room at night."

Keeping the room well-lit at night is beneficial for falls prevention, as adequate lighting can help individuals see potential hazards and navigate their environment safely. While this statement reflects a general awareness of falls prevention principles related to lighting, it is not as specific or directly related to falls prevention during activities like bathing (as mentioned in option C).