The nurse is assisting with patient data collection in a clinic. The nurse is assigned to a young female patient who has an older male friend present at her bedside. The patient is nervous, timid, very thin, and with poor hygiene and lets the friend answer all of the nurse's questions. What actions should the nurse take?

Explanation:

A. Nonmaleficence: This ethical principle emphasizes the duty of healthcare professionals to avoid causing harm to patients. It involves refraining from actions that could potentially harm the patient, whether physical, emotional, psychological, or social. Nonmaleficence is about acting in a way that promotes the well-being and safety of patients and avoiding actions that could result in harm or injury.

B. Fidelity: Fidelity pertains to the faithfulness, loyalty, and honoring of commitments and promises made to patients. It involves maintaining trust and being truthful in interactions with patients.

C. Beneficence: Beneficence involves the obligation to do good and promote the well-being of patients. It includes actions aimed at benefiting patients, such as providing effective treatments, interventions, and support to improve their health outcomes and quality of life.

D. Justice: Justice relates to fairness and equality in healthcare. It involves the fair distribution of resources, allocation of care, and treatment decisions without discrimination or bias, ensuring that all patients receive equitable care based on their needs and circumstances.

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.