A nurse refers a client to a specialist for further evaluation. What level of prevention is this?

Choice A rationale
Placing all beds in the high position increases the risk of injury if a patient falls out of bed. It is generally recommended to keep beds in the lowest position to minimize the distance a patient would fall, thereby reducing the risk of injury.

Choice B rationale
Using color-coded wristbands is an effective way to quickly communicate a patient’s fall risk status to all healthcare providers. This visual cue helps ensure that all staff members are aware of the patient’s fall risk and can take appropriate precautions.
Choice C rationale
Conducting frequent rounds of patient rooms allows healthcare providers to regularly check on patients, address their needs, and identify any potential fall hazards. This proactive approach helps in preventing falls by ensuring that patients are safe and their environment is free of obstacles.
Choice D rationale
Providing non-skid socks helps prevent slips and falls by giving patients better traction when walking. These socks are especially useful for patients who may be unsteady on their feet or are at a higher risk of falling.

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.