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. Begin abdominal girth measurements.
Abdominal girth measurements may be important for assessing fluid status in clients with liver disease and ascites, but in this case, the elevated polymorphonuclear leukocyte count indicates a possible infection, requiring immediate intervention.

B. Review serum protein levels.
While monitoring serum protein levels is important in clients with liver disease, the priority in this situation is to address the potential infection indicated by the elevated leukocyte count.

C. Assess neurological status.
Neurological assessment may be relevant in some cases, but it is not the priority in a client with suspected infection after a paracentesis.

D. Initiate antibiotic therapy.
Given the client's symptoms and the elevated polymorphonuclear leukocyte count in the ascitic fluid, indicating possible infection (spontaneous bacterial peritonitis), initiating antibiotic therapy is the priority action to address the infection and prevent further complications.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

A. Functional Improvement: This is crucial to assess because it indicates the effectiveness of the interventions implemented, such as physical and occupational therapy, and the overall progress of the client in regaining independence in activities of daily living. Tracking functional improvements helps determine if the client's physical abilities, mobility, and self- care skills are improving over time, which is essential for their overall well-being and quality of life.

B. Psychological Assessment: This aspect is important to evaluate because it helps gauge the client's mental and emotional well-being. Elderly individuals who are subjected to neglect or mistreatment, as in this case, may experience psychological distress, such as depression, anxiety, or feelings of helplessness. Monitoring the client's psychological status allows the nurse to identify any signs of emotional distress or trauma resulting from their situation, enabling appropriate interventions to support their mental health and emotional stability.

Additionally, assessing the caregiver's psychological well-being is also crucial as they may experience stress, burnout, or emotional strain from the caregiving responsibilities, which can impact the quality of care provided to the client.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness. Following a paracentesis, the nurse receives laboratory results. Exhibits After notifying the healthcare provider, which action should the nurse take next?

Correct Answer is D

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

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