A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (ISBARR) on a client. Which of the following information should be included in the situation component?

Choice A reason: This statement is incorrect because a nurse’s personal values can and do influence ethical decisions. The nurse should be aware of their own values and how they affect their judgment and actions. The nurse should also respect the values of others and avoid imposing their own values on the clients or colleagues.
Choice B reason: This statement is incorrect because value clarification is not related to maintaining clinical competency. Value clarification is a process of identifying, examining, and prioritizing one’s values. It can help the nurse to understand their own values and beliefs, as well as those of the clients and the profession.
Choice C reason: This statement is correct because it is important that the nurse is aware of the client’s values. The nurse should assess the client’s values and preferences, and incorporate them into the plan of care. The nurse should also respect the client’s right to self-determination and autonomy, and support the client in making informed decisions.
Choice D reason: This statement is incorrect because a nurse's behaviors and actions are not called values. Values are the beliefs and principles that guide one’s decisions and actions. A nurse's behaviors and actions are the expressions of their values, as well as their knowledge, skills, and attitudes.

Choice A reason: This statement is false and should not be included in the teaching. Placing the client on 12hour observation is not enough to ensure the client's safety, as the client may still attempt suicide when the nurse is not watching. The client should be placed on continuous observation, preferably one-to-one, until the risk of suicide is reduced.

Choice B reason: This statement is false and should not be included in the teaching. Encouraging visitors to bring items to the client is not advisable, as some items may pose a potential danger to the client, such as sharp objects, medications, or alcohol. The nurse should inspect and limit the items that the client and the visitors have access to, and remove any items that could be used for self-harm.

Choice C reason: This statement is false and should not be included in the teaching. Encouraging visitors for the client at any time is not appropriate, as some visitors may have a negative impact on the client, such as those who are abusive, judgmental, or unsupportive. The nurse should screen and monitor the visitors, and allow only those who are helpful and respectful to the client.

Choice D reason: This statement is true and should be included in the teaching. Removing harmful objects from the client's room is a priority action that the nurse should take to prevent the client from harming themselves. The nurse should search the client's room and belongings, and remove any objects that could be used for suicide, such as knives, scissors, razors, belts, cords, or plastic bags.