The nurse is reporting a change in patient condition to the physician. Which statement made by the nurse would demonstrate the S (situation) of ISBAR?

Choice A reason: This statement is appropriate because it clearly communicates the client’s condition (weakness) and the specific task (assist with ambulation to prevent falls). It provides the UAP with a clear purpose and safety goal. Preventing falls is a major priority in long-term care facilities, and UAPs are trained to assist with ambulation under supervision. The instruction is measurable and actionable, making it a safe and effective delegation.

Choice B reason: This statement is not appropriate because documenting vital signs is outside the scope of practice for a UAP. While UAPs can measure and record vital signs, the responsibility for documentation in the medical record belongs to licensed staff. Delegating documentation to a UAP risks inaccurate charting and violates professional standards. Therefore, this does not effectively communicate an appropriate assignment.

Choice C reason: This statement is incomplete and vague. While encouraging position changes is within the UAP’s scope, the instruction lacks specificity about frequency, timing, or which patients require repositioning. Effective delegation requires clear, measurable instructions. Without these details, the UAP may not understand the priority or urgency, making this statement insufficient for safe delegation.

Choice D reason: This statement is appropriate because it specifies the patient (Mrs. Brown), the task (check blood pressure), and the time frame (report back by 7:30 AM). It provides a clear, measurable assignment that is within the UAP’s scope of practice. UAPs are trained to measure vital signs and report findings to licensed staff. This instruction ensures accountability and timely communication, which supports safe patient care.

Choice A reason: This is incorrect because family members cannot force the patient to bathe. The nurse must first assess the patient’s reasons for refusal and address them appropriately.

Choice B reason: This is inappropriate because a sedative is not indicated for refusal to bathe. Sedation does not address the underlying issue and poses unnecessary risks.

Choice C reason: This is the correct action because assessing the patient’s reasons for refusal allows the nurse to understand barriers and provide education. Informing the patient of risks such as infection and skin breakdown promotes informed decision-making and respects autonomy.

Choice D reason: This is incorrect because forcing the patient to bathe violates autonomy and may cause distress. Patient-centered care requires collaboration and respect for choices, even when encouraging hygiene.