A nurse is preparing to provide report on a client using the Situation-Background- Assessment-Recommendation (SBAR) Communication tool.
Identify the order in which the nurse should give report.

Observe the client’s body language during the conversation. This action will help the nurse to assess the client’s nonverbal cues and emotions, which can enhance communication and understanding. The nurse should also determine the client’s understanding several times during the conversation and use lay terms if possible.

Choice A is wrong because avoiding asking the client personal questions can hinder rapport building and prevent the nurse from obtaining important information about the client’s health and needs.

Choice C is wrong because maintaining eye contact with the interpreter when asking questions can show disrespect and disinterest to the client and his family. The nurse should look at the client and his family when asking questions, not at the interpreter.

Choice D is wrong because including medical terminology when discussing the client’s condition can confuse the client and his family and create barriers to communication. The nurse should use simple and clear language that the client and his family can understand.

Offer the client fluids high in fiber and protein every hour. This is because clients who have bipolar disorder and are experiencing mania are at risk of dehydration, malnutrition, and weight loss due to increased activity, poor intake, and impaired judgment. Fluids high in fiber and protein can help prevent constipation and promote satiety.

Choice B is wrong because monitoring the client’s vital signs twice per day is not enough for a client who has mania. The nurse should monitor the client’s vital signs more frequently, at least every 4 hours, to assess for signs of dehydration, infection, or cardiac complications.

Choice C is wrong because encouraging the client to participate in group therapy activities each day can increase the client’s stimulation and agitation. The nurse should provide a calming environment with fewer stimuli and solitary activities for a client who has mania.

Choice D is wrong because weighing the client three times per week is not sufficient for a client who has mania. The nurse should weigh the client daily to monitor for weight loss and fluid imbalance.