The nurse is caring for a client who received a kidney transplant 2 years ago and is now showing signs of rejection. Which assessment findings should the nurse report to the healthcare provider?

Reference Range:

• White Blood Cell (WBC) [5000 to 10,000/mm3 (5 to 10 x 109/L)]

A. Currently prescribed medications are important background information that may contribute to the client’s condition, but they are not the immediate priority in SBAR communication.

B. Increasing confusion is the most urgent information and should be reported first under the “Situation” component of SBAR. SBAR prioritizes presenting the current problem or change in condition before providing background or additional context. Early reporting of acute changes, such as sudden confusion in an older adult, is essential for timely assessment and intervention, as it may indicate a serious issue like delirium, infection, or head injury.

C. The fall at home is relevant background information but does not describe the immediate concern that prompted the need for provider notification. It would be communicated under the “Background” section.

D. The presence of the client’s healthcare power of attorney is important for decision-making and consent but is secondary to reporting acute changes in the client’s condition. It would be included as supporting information if needed.

Rationales for Correct Answers:

• Safety: According to Maslow’s Hierarchy of Needs and the nursing process, safety is always the highest priority for a psychiatric patient. While the client is not currently expressing suicidal ideation, the presence of worsening depressive symptoms over three years places her at a high risk for a safety crisis.
• Report of hopelessness: In psychiatric nursing, hopelessness is a primary red flag and a major risk factor for suicide. It is a subjective state where the individual sees no alternative or way out of their current pain. Because the client describes a "growing sense of hopelessness" that has progressively worsened, it serves as the most critical evidence requiring safety-related follow-up.

Rationales for Incorrect Answers

• Self-care deficit: While the client clearly has a self-care deficit (oily, matted hair; stained clothing), hygiene is considered a "lower-level" need compared to the immediate risk of self-harm or psychological collapse associated with safety.
• Nutritional imbalance: The client's weight gain and carbohydrate cravings are characteristic of SAD, but they are not life-threatening. Metabolic needs are prioritized after safety and stability have been established.

• Matted hair: This is objective evidence of a self-care deficit. While significant, it does not provide evidence for a safety priority as directly as a psychological report of hopelessness does.
• Six-pound weight gain in 2 weeks: This is objective evidence of nutritional imbalance and is a physical manifestation of her depression. It does not indicate an immediate safety risk.