Exhibits

The practical nurse (PN) calls the healthcare provider to notify them that the heart rate is too low to administer the digoxin.

Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format. Each column must have at only one answer selected.

A. Alteration in comfort: Restlessness, shallow breathing, and clenching teeth are strong indicators of discomfort or pain, especially in a client with aphasia who cannot verbalize needs. Assessing for pain or other sources of distress is the priority to address the client’s immediate comfort and prevent further deterioration.
B. Deficit in diversional activity: While limited activity can impact emotional health, signs like restlessness and physical tension suggest an immediate physical problem rather than boredom or inactivity. Comfort issues must be addressed first before considering diversional needs.
C. Elevated blood pressure: Stroke patients are at risk for hypertension, but restlessness and shallow respirations alone do not directly indicate elevated blood pressure. Blood pressure may rise secondary to pain or distress, but comfort assessment is still the initial focus.
D. Change in blood glucose level: Blood glucose fluctuations can cause changes in mental status or energy levels, but the client’s symptoms of clenching teeth and shallow breathing more strongly point toward discomfort or pain rather than hypoglycemia or hyperglycemia.

A. Quickly complete tasks and leave client's room: Leaving the room quickly can make the client feel abandoned and isolated at a time when emotional support is crucial. Presence and attentive listening are important components of compassionate end-of-life care.
B. Request the chaplain to talk with client: While involving spiritual support services can be valuable, immediately referring the client to someone else may delay emotional comfort. The PN should first offer direct support before suggesting additional resources.
C. Ask the client if praying together would help: Offering prayer without knowing the client’s spiritual preferences might be inappropriate or uncomfortable for some individuals. It's better initially to offer silent presence and allow the client to express their needs if they wish.
D. Remain quietly in the client's room for a while: Staying quietly with the client conveys empathy, presence, and support. Nonverbal comfort allows the client space to process emotions and invites communication if they are ready, building trust and emotional security during a difficult moment.