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: Obtaining a detailed history is the first action that the nurse should take. History can help the nurse determine the cause, frequency, and severity of the bruises, as well as the child's relationship with the abuser and the risk of further harm. History can also help the nurse assess the child's physical and emotional state, and provide evidence for reporting the abuse later.
Choice B reason: Reporting the suspected abuse to the authorities is not the first action that the nurse should take. The nurse should report the abuse only after obtaining a history and confirming the suspicion. Reporting the abuse prematurely can jeopardize the child's safety and the nurse's credibility. The nurse should also follow the legal and ethical guidelines for reporting abuse in their jurisdiction.
Choice C reason: Requesting a social services referral is not the first action that the nurse should take. The nurse should request a social services referral only after reporting the abuse and ensuring the child's protection. A social services referral can help the child access resources and support, such as counseling, legal aid, foster care, etc. The nurse should also collaborate with the social worker and other members of the interdisciplinary team to provide holistic care for the child.
Choice D reason: Telling the child what will happen to her when the abuse is reported is not the first action that the nurse should take. The nurse should tell the child what will happen to her only after obtaining a history and reporting the abuse. The nurse should also use age-appropriate language and reassure the child that the abuse is not her fault and that she is not alone. The nurse should avoid making promises that they cannot keep, such as saying that the abuser will never hurt her again.