A nurse is giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of SBAR?

Explanation:

A. Avoid touching the client:

While it's essential to be gentle and respectful when touching an unresponsive client, avoiding all touch may not be appropriate. Touch can be a comforting and reassuring gesture, and many clients at the end of life benefit from gentle touch, such as holding their hand or providing a gentle massage.

B. Continue to talk to the client as if they are awake:

Talking to the client, even if they are unresponsive, is encouraged. Hearing is often the last sense to diminish, and talking to the client in a soothing and reassuring manner can provide comfort and a sense of presence. The nurse should speak calmly and compassionately, addressing the client by name and providing updates on care activities.

C. Limit the client's visitors to one at a time:

Limiting the number of visitors and controlling the environment can help maintain a calm and peaceful atmosphere for the client. However, the specific number of visitors allowed at a time may vary based on the client's preferences, cultural considerations, and facility policies. It's important to respect the client's wishes regarding visitors while ensuring their comfort and well-being.

D. Whisper when talking in the client's room:

Whispering may not be necessary unless the client is particularly sensitive to loud noises. Speaking in a calm and gentle tone is generally more appropriate, as it allows the client to hear clearly without causing unnecessary strain or confusion.

Explanation:

A. "Reporting is voluntary for health care workers."

This statement is incorrect. Reporting child abuse is not voluntary for healthcare workers; it is a legal requirement in many jurisdictions. Failure to report suspected abuse can lead to legal and professional consequences.

B. "Civil liability can result if the abuse can't be proven."

While civil liability may be a concern in some situations, it is not the primary reason for reporting child abuse. The main purpose of reporting is to ensure the safety and well-being of the child, not to prove abuse in a legal sense.

C. "Evidence of abuse must be collected prior to reporting."

This statement is incorrect. While collecting evidence can be important in legal proceedings, it is not the responsibility of healthcare workers to collect evidence of abuse before reporting. Suspected cases of abuse should be reported promptly to the appropriate authorities, who are responsible for investigating and gathering evidence.

D. "If suspicion of abuse exists then reporting is mandatory."

This statement correctly reflects the legal and ethical obligation of healthcare workers to report suspected cases of child abuse. Healthcare professionals are mandated reporters, which means they are required by law to report any suspicion of child abuse or neglect, even if there is no concrete evidence. Reporting is not voluntary for healthcare workers, and failure to report suspected abuse can result in serious consequences, including legal penalties and professional sanctions.