The nurse is assisting with patient data collection in a clinic. The nurse is assigned to a young female patient who has an older male friend present at her bedside. The patient is nervous, timid, very thin, and with poor hygiene and lets the friend answer all of the nurse's questions. What actions should the nurse take?

Explanation:

A. "The client has developed drooping facial features."

This statement provides specific information about a recent change in the client's condition, which is relevant background information. It helps the provider understand one of the key reasons for the communication.

B. "The client may benefit from a neurology consult."

While suggesting a neurology consult is a potential recommendation (R) in the SBAR tool, it is not part of the Background (B) component. Background information typically focuses on factual data about the client's history, current condition, and pertinent details relevant to the situation.

C. "The client is disoriented and pupils are slow to respond to light."

Similar to option B, this statement describes the client's assessment findings and current condition rather than providing background information. It would be more appropriate in the Assessment (A) component of the SBAR tool.

D. "The client has a history of hypertension."

This statement provides relevant background information about the client's medical history, specifically their history of hypertension. Including this information in the Background component helps the provider understand the client's baseline health status, which is important for evaluating the current situation.

Explanation:

A. Bathtub with rails:

Having a bathtub with rails is generally considered a safety measure, as it can assist the client in safely entering and exiting the bathtub. Rails provide support and stability, especially for older adults who may have mobility issues. Therefore, this finding is not typically identified as a safety risk.

B. Raised toilet seats:

Raised toilet seats can also be beneficial for older adults with mobility challenges, as they make it easier to sit down and stand up from the toilet. Similar to bathtub rails, raised toilet seats are considered a safety measure rather than a safety risk.

C. Electric cords behind furniture:

Electric cords behind furniture pose a tripping hazard, especially for older adults who may have reduced balance or vision. Trips and falls can lead to serious injuries, so it's important to keep walkways clear of obstacles, including electric cords. Therefore, this finding is identified as a safety risk.

D. Water heater temperature 54.4°C (130° F):

The recommended safe water heater temperature to prevent scalding injuries is typically around 48.9°C (120°F). A water heater temperature of 54.4°C (130°F) is higher than the recommended safe range and can increase the risk of scalding injuries, especially for older adults with sensitive skin or reduced sensation. Therefore, this finding is identified as a safety risk.

E. Throw rugs:

Throw rugs are common tripping hazards, particularly if they are not secured to the floor or have curled edges. Older adults can easily trip on throw rugs, leading to falls and injuries. It's recommended to remove or secure throw rugs to reduce the risk of falls, making this finding a safety risk.