A nurse is assisting with the care of a client.

The nurse is collecting data from the client.

Select words from the choices to fill in each blank in the following sentence

The nurse should identify that

____

and

____

Indicate manifestations of borderline personality disorder

A) *The client's partner visited earlier today for 2 hours: While this information is helpful for the personal context of the client, it is not essential to the clinical care of the client or a critical part of the handoff. The change-of-shift report should focus on relevant clinical information that affects ongoing care, such as treatment responses, medications, or changes in condition.

B) "The client reports pain is reduced when he is positioned on his side": This is important clinical information that should be included in the report. It provides insight into the client’s current comfort measures and pain management strategies. Sharing how the client’s pain can be alleviated will help the next nurse provide the most effective care and manage the client's comfort.

C) "The client received the prescribed antibiotic every 8 hours": While medication administration is an essential part of the report, this specific detail is unnecessary if the medication administration schedule is already part of the client's medical record or the nurse's medication administration documentation. The change-of-shift report should focus on whether the client has had any reactions, responses, or issues related to the medication, rather than simply repeating the schedule.

D) "The client's mother died 4 years ago from breast cancer": This personal history may be relevant to understanding the client's emotional well-being but is not essential in a clinical report unless it directly impacts current care. If the client's grief or family history affects their current health status (such as in the case of emotional distress, family health risks, or health behaviors), it may be relevant, but it's generally not a priority in a shift report unless it has immediate implications for care.

A) Patient care technician: While a patient care technician (PCT) is an important part of the healthcare team, their role generally focuses on providing direct patient care tasks such as monitoring vital signs, assisting with activities of daily living, and supporting the nursing staff. They do not have the expertise to address complex medication interactions, so they are not the appropriate referral in this scenario.

B) Psychologist: A psychologist focuses on providing mental health support, including therapy and counseling. While medication interactions may be of concern in patients receiving psychiatric medications, a psychologist does not typically have the medical knowledge to assess or manage pharmacological interactions. The nurse would not make a referral to a psychologist for this issue.

C) Social worker: Social workers are important for addressing the social and emotional needs of patients, including helping with care coordination, support, and resources. However, they are not trained to evaluate or address medication interactions. This issue would be outside of their scope of practice.

D) Advanced practice nurse: An advanced practice nurse (APN), such as a nurse practitioner or clinical nurse specialist, has advanced training in diagnosing, managing, and prescribing medications. They are the most appropriate team member to assess the potential interactions of the client’s medications and make any necessary adjustments to their medication regimen. The nurse should refer the client to an APN for expertise in this area.