A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform?

Rationale:

A. A client who has Guillain-Barre syndrome requires close monitoring and specialized care due to progressive weakness and potential respiratory issues. This client's care may involve more complex needs that are beyond the AP's scope.

B. A client who has a lumbosacral spinal tumor is likely to have fewer immediate needs related to eating assistance, making this task appropriate to delegate to the AP. The client’s primary concern may be mobility or pain management, but meal assistance is a routine task.

C. A client who has systemic sclerosis may have issues with gastrointestinal motility and swallowing, requiring more careful feeding assistance and monitoring, which should be performed by the nurse.

D. A client who has amyotrophic lateral sclerosis (ALS) requires specialized care for swallowing difficulties and respiratory issues, making it inappropriate to delegate meal assistance to the AP.

Rationale:

A. “There are no provider's prescriptions available.” This reflects the Situation (current problem), not background.

B. The B (Background) step of SBAR includes relevant clinical history and context that led to the current situation. Explaining how the client was found provides important background information that helps the provider understand the circumstances surrounding the client’s condition.

C. “The client should be seen by a neurologist.” This is part of the Recommendation step, where the nurse suggests actions or next steps.

D. “The client is disoriented. Pupils are slow to respond to light.” This belongs in the Assessment step, as it describes the nurse’s clinical findings.