A nurse is assisting an older adult client who sometimes loses their balance while walking. Which of the following devices is most important for the nurse to use when helping the client ambulate?

A. Call for assistance. While calling for help may be necessary if the patient becomes unresponsive or falls, the priority action is to ensure their safety immediately by helping them sit down.

B. Assist the patient in sitting down on the bed. The patient is experiencing dizziness upon standing, which could indicate orthostatic hypotension or another condition. The best immediate action is to help them sit down to prevent a fall or further complications.

C. Assess the vital signs for orthostatic hypotension. While assessing for orthostatic hypotension is important, it should be done after ensuring the patient is safe by sitting them down.

D. Notify the provider. The provider may need to be informed if the dizziness persists or if there is an underlying medical issue. Still, immediate intervention (sitting the patient down) takes priority before notifying the provider.

A. Providing a detailed SBAR report to the primary nurse: SBAR (Situation, Background, Assessment, Recommendation) is a standard communication tool used among healthcare professionals to ensure continuity of care. Since this report is given to the primary nurse who is part of the healthcare team, it does not violate confidentiality.

B. Collaborating with the patient care technician for hygiene care: Patient care technicians (PCTs) are part of the healthcare team, and sharing necessary patient information with them to ensure hygiene care does not breach confidentiality.

C. Discussing the client's medications with the clinical instructor: A clinical instructor is responsible for overseeing student learning and patient safety. As long as the discussion is conducted in an appropriate setting (e.g., away from unauthorized persons), it does not violate confidentiality.

D. Writing the client's initials on the student care plan: Even using initials instead of a full name can still be considered identifiable information if someone can link it to a specific patient. To maintain confidentiality, students should use de-identified data in their care plans.