A client is brought to the emergency department after falling from of a ladder and is showing signs of confusion and disorientation. The spouse states the client appeared to have lost consciousness. The nurse is provided with a list of current medications and healthcare power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

Currently prescribed medications.

Falling from a ladder as reason for admission.

Increasing confusion of the client.

Client's healthcare power of attorney.

Answer and Explanation

The Correct Answer is C

A. Currently prescribed medications are important information, but in this emergent situation, the nurse should first report on the client's condition and immediate concerns.

B. Falling from a ladder as the reason for admission is relevant information, but it does not address the immediate clinical concern of the client's altered mental status.

C. Reporting the increasing confusion of the client is the priority as it highlights the acute change in neurological status, which may indicate a more critical issue such as intracranial injury or neurological impairment.

D. The client's healthcare power of attorney is important for long-term care planning, but it is not the immediate concern when the client presents with altered mental status and potential head
trauma.

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Correct Answer is D

Explanation

A. Verify the prothrombin time (PT).
While it is important to verify coagulation status in patients with atrial fibrillation to ensure they are not at high risk for bleeding, this is not the most critical step immediately prior to
cardioversion. The PT is more relevant if anticoagulation therapy is being managed.

B. Administer prescribed sedative.
Administering a sedative is important for patient comfort during the procedure, but it is not the most critical step that directly affects the success and safety of the cardioversion itself.

C. Select a monitor lead with a tall R wave.
Selecting a monitor lead with a tall R wave helps in accurately synchronizing the cardioversion shock with the R wave, but this is secondary to activating the synchronization mode which is critical to avoid delivering a shock during the vulnerable period of the cardiac cycle.

D. Activate the synchronization mode.
This is the correct answer. The most important action before deploying the current for cardioversion is to ensure the defibrillator is in synchronization mode. Synchronization ensures that the electrical shock is delivered at the correct time during the cardiac cycle, specifically on the R wave of the QRS complex, to avoid inducing ventricular fibrillation. This is crucial for
patient safety.

A. A Guide in moving the non affected limb to override the sensation being experienced. B. B Reassure that this can be a normal postsurgical sensation. C. C Affirm that a prosthetic with physical therapy will gradually improve the symptoms. D. D Explain that the sensations of tingling and pain are not real.

Correct Answer is B

Explanation

A. Guide in moving the non-affected limb to override the sensation being experienced.
Encouraging movement of the non-affected limb may not effectively address phantom limb pain and could potentially exacerbate discomfort or distress.

B. Reassure that this can be a normal postsurgical sensation.
Phantom limb pain is a common phenomenon after amputation surgeries. Providing reassurance that this sensation is normal can help alleviate anxiety and provide comfort to the adolescent.

C. Affirm that a prosthetic with physical therapy will gradually improve the symptoms.
While a prosthetic limb and physical therapy can help in the long term, they may not immediately address the phantom limb pain experienced in the early postoperative period.

D. Explain that the sensations of tingling and pain are not real.
Invalidating the adolescent's experience of phantom limb pain by suggesting that the sensations are not real may worsen distress and anxiety. It's essential to acknowledge the client's experience and provide supportive care.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is providing postoperative care for an adolescent who had an amputation of the left leg for osteosarcoma. The adolescent describes experiencing phantom limb pain. Which non pharmacological intervention should the nurse provide?

Correct Answer is B

Explanation

In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

An older adult client arrives at the clinic reporting decreased strength in knees and in handgrips. Which action should the nurse include in a functional assessment of the client?

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Exhibits The nurse reviews the findings in the history and physical. Select from Word Choices to complete the sentence. The nurse recognizes that dropdown ,dropdown and dropdown are findings consistent with elder mistreatment.

Exhibits The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence. The client is at immediate risk for developing dropdown-1,dropdown-2 and dropdown-3

The nurse observes erythema under the chin of a client receiving oxygen at 2 L/minute per nasal cannula. Which intervention should the nurse implement?