A nurse is teaching a client who wishes to lose weight.
Which of the following should the nurse include in the teaching?

Choice A rationale
The statement “The vital signs are stable” is incorrect for the fifth step of the SBAR communication tool. The fifth step in SBAR is the Recommendation step, where the nurse provides a recommendation or request for what action should be taken next. Stating that the vital signs are stable does not provide a clear recommendation or action plan for the provider to follow.
Choice B rationale
The statement “The client has a history of high blood pressure” is incorrect for the fifth step of the SBAR communication tool. This information belongs in the Background step, where the nurse provides relevant clinical background information about the patient’s condition. The Recommendation step should focus on what action the nurse recommends based on the assessment.
Choice C rationale
The statement “The client should be seen by a neurologist” is correct for the fifth step of the SBAR communication tool. In the Recommendation step, the nurse provides a clear and specific recommendation for what action should be taken next. Recommending that the client be seen by a neurologist is an appropriate and actionable recommendation based on the nurse’s assessment.
Choice D rationale
The statement “The client is experiencing severe headaches” is incorrect for the fifth step of the SBAR communication tool. This information belongs in the Assessment step, where the nurse provides an analysis of the patient’s current condition. The Recommendation step should focus on what action the nurse recommends based on the assessment.

Choice A rationale
On initial evaluation by the home health nurse, a comprehensive assessment is typically performed to gather baseline data. This initial assessment is thorough and includes a detailed history and physical examination to understand the patient’s overall health status. It is not a partial ongoing assessment, which is more focused and conducted after the initial comprehensive assessment to monitor specific issues or changes in the patient’s condition.
Choice B rationale
Reassessing a client for pain after giving pain medication is an example of a partial ongoing assessment. This type of assessment is focused on evaluating the effectiveness of an intervention, such as pain medication, and determining if further action is needed. It involves collecting specific data related to the patient’s pain levels and response to treatment, rather than a comprehensive evaluation of their overall health.
Choice C rationale
Checking skin assessment on a patient with a medical device in place is also an example of a partial ongoing assessment. This focused assessment is conducted to monitor the condition of the skin around the medical device, looking for signs of pressure ulcers, infection, or other complications. It is not a comprehensive assessment but rather a targeted evaluation of a specific area of concern.

Choice D rationale
Preparing the client for discharge involves a comprehensive assessment to ensure that the patient is ready to leave the healthcare facility and can manage their care at home. This assessment includes evaluating the patient’s physical, psychological, and social needs, as well as their ability to perform activities of daily living. It is not a partial ongoing assessment, which is more focused and conducted during the course of care to monitor specific issues.