A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (ISBARR) on a client. Which of the following information should be included in the situation component?

Choice A reason: This statement does not indicate an understanding of acute care, but rather a misconception and a lack of responsibility. Acute care is a level of health care that provides immediate and short-term treatment for severe or life-threatening conditions, such as asthma attacks. Acute care requires the parents to stay with their child and participate in their care plan.

Choice B reason: This statement does not indicate an understanding of acute care, but rather a denial and a delay of treatment. Acute care is not provided at home, but at a specialized facility that has the equipment and staff to handle emergencies. Waiting for the nurse to come may worsen the child's condition and increase the risk of complications.

Choice C reason: This statement does not indicate an understanding of acute care, but rather an exaggeration and a misunderstanding of the duration of treatment. Acute care is not meant to last for a long time, but only until the condition is stabilized or resolved. The length of stay at an acute care facility depends on the severity of the condition and the response to treatment, but it is usually less than a month.

Choice D reason: This statement indicates an understanding of acute care, as it reflects the main goal and intervention of acute care for asthma. Acute care for asthma involves administering medications that can quickly relieve the symptoms and prevent further inflammation of the airways. Medications may include bronchodilators, corticosteroids, oxygen, and others.

Choice A reason: SOAP documentation is not the correct method for documenting only unexpected findings. SOAP documentation requires the nurse to document both normal and abnormal findings, as well as the plan of care for the client.

Choice B reason: Problem oriented medical record (POMR) is not the correct method for documenting only unexpected findings. POMR is a method that organizes the documentation around the client's problems, rather than the source of data. It consists of four components: database, problem list, plan, and progress notes.

Choice C reason: Focus charting (DAR) is not the correct method for documenting only unexpected findings. Focus charting is a method that uses the nursing process and the client's perspective to document the client's care. It consists of three components: data, action, and response.

Choice D reason: Charting by exception (CBE) is the correct method for documenting only unexpected findings. CBE is a method that assumes that all standards of care are met unless otherwise documented. It allows the nurse to document only significant or abnormal findings, such as changes in the client's condition, interventions, or outcomes.