During a therapy session, a client begins to cry while discussing a traumatic experience. What is the nurse’s most appropriate response?

Choice A rationale
Reporting unusual lung sounds requires assessment skills that are beyond the scope of practice for an unlicensed assistive personnel (UAP). UAPs are not trained to interpret or evaluate clinical data, which is essential for identifying unusual lung sounds. This task should be performed by a licensed nurse who can accurately assess and respond to the findings.
Choice B rationale
Providing assistance with morning care is within the scope of practice for UAPs. This task involves helping the patient with activities of daily living such as bathing, dressing, and grooming, which do not require clinical judgment or assessment skills. It is a routine task that UAPs are trained to perform safely and effectively.
Choice C rationale
Teaching the patient about a heart-healthy diet involves providing education and requires a thorough understanding of the patient’s medical condition and dietary needs. This task should be performed by a licensed nurse or dietitian who has the knowledge and skills to provide accurate and comprehensive education.
Choice D rationale
Checking the client’s blood pressure medication involves administering medication, which is outside the scope of practice for UAPs. Medication administration requires knowledge of pharmacology, the ability to assess the patient’s response to the medication, and the ability to recognize and respond to potential side effects. This task should be performed by a licensed nurse.

Choice A rationale
The assessment component of the SBAR report includes the nurse’s evaluation of the patient’s condition, such as pain level, blood pressure, and heart rate. This information is critical for the provider to understand the patient’s current status and make informed decisions.
Choice B rationale
The situation component of the SBAR report provides a brief overview of the patient’s current situation, such as the reason for the call or the immediate concern. It does not include detailed assessment data.
Choice C rationale
The recommendation component of the SBAR report includes the nurse’s suggestions for the next steps or actions to be taken. It does not include the patient’s assessment data.
Choice D rationale
The background component of the SBAR report provides relevant medical history and context for the patient’s current condition. It does not include the detailed assessment data.