A nurse is evaluating a client's understanding of their medication

Exhibits

The nurse returns in 1 week for a follow up appointment. For each client statement indicate if the client understood the teaching or needs further teaching

A. Have the client move each limb independently through its complete range of motion: This describes active range of motion exercises, which involve joint mobility but do not focus on muscle strengthening through tension as isometric exercises do.

B. Ask the client to move her arms and legs while applying slight resistance: This describes isotonic resistance exercises, where movement occurs against an external force. Isometric exercises, in contrast, involve no visible joint movement.

C. Instruct the client to tighten muscle groups for a short period, and then relax: Isometric exercises involve contracting muscles without moving the associated joint. This action maintains muscle strength and circulation during bedrest, reducing the risk of deconditioning.

D. Move the client's limbs through their complete range of motion: This describes passive range of motion, which maintains joint flexibility but does not engage the client’s muscles actively. It does not provide the benefits of isometric strengthening.

A. Intracranial pressure readings: ICP readings are current assessment data and belong in the Assessment segment of SBAR rather than the background. These values help the oncoming nurse interpret the client’s current status but are not part of historical or contextual information.

B. Plan of care changes for upcoming shift: Changes in the plan of care are included in the Recommendation segment of SBAR. This informs the oncoming nurse of anticipated actions but is not part of the client’s background history.

C. Code status: Code status is typically included in the Situation segment, as it is critical for immediate decision-making during emergencies, not background context.

D. Glasgow score: The Glasgow Coma Scale score provides a summary of the client’s neurological status prior to or at the time of the shift report and reflects baseline information relevant to the client’s condition. Including it in the Background segment gives context for current changes and ongoing care.