A nurse is supervising a newly licensed nurse who is caring for a client on a behavioral health unit.

Exhibits

Complete the following sentence by using the list of options.

The nurse should instruct the newly licensed nurse to first

dropdown

then

dropdown

.

Rationale:

A. Assessment includes the current status and vital signs of the client, which are part of the information the nurse provides to assess the client’s condition.

B. Situation describes the problem or concern that prompted the communication, not detailed vital signs.

C. Background provides context or history relevant to the situation but does not include current vital signs.

D. Recommendation involves suggesting actions or solutions but does not include the current condition details.

Rationale:

A. A child who is experiencing sickle cell crisis may require isolation to prevent infection and avoid complications related to sickle cell disease.

B. A child who has a head injury may require specific monitoring and precautions that are not suitable for a postoperative appendectomy patient.

C. A child who has a new diagnosis of type 1 diabetes mellitus generally has a stable condition that can be managed with routine care and would be an appropriate roommate for a postoperative appendectomy patient.

D. A child who has streptococcal pharyngitis could pose an infection risk to the postoperative appendectomy patient and is better kept separate to prevent the spread of infection.