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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Digoxin.
Digoxin is a cardiac glycoside that helps increase the force of myocardial contraction and is generally used to treat heart failure. It does not typically pose a significant risk for cardiogenic shock.

B. Hydrochlorothiazide.
Hydrochlorothiazide is a diuretic used to manage fluid retention in heart failure. It can cause electrolyte imbalances but is not directly linked to causing cardiogenic shock.

C. Nadolol.
Nadolol is a beta-blocker, which can reduce the heart rate and the strength of heart contractions. In a client with severe heart failure, excessive beta-blockade can lead to a significant decrease in cardiac output, increasing the risk for cardiogenic shock.

D. Captopril.
Captopril is an ACE inhibitor that helps manage heart failure by reducing afterload and preload.
While it can cause hypotension, it is not typically associated with a direct risk of cardiogenic shock.

A. Gastric Irritation. B. Moon facies. C. Abdominal striae. D. Rapid weight gain.

Correct Answer is D

Explanation

A. Gastric Irritation.

While gastric irritation is a common side effect of prednisone, it is not as critical as some other potential adverse effects and can often be managed with medication or dietary changes.

B. Moon facies.

Moon facies is a sign of Cushing's syndrome, a potential long-term side effect of prednisone, but it does not require immediate reporting compared to more acute symptoms.

C. Abdominal striae.
Abdominal striae (stretch marks) are a long-term side effect of corticosteroids like prednisone, but they are not typically an urgent concern.

D. Rapid weight gain.

This is the correct answer because rapid weight gain can indicate fluid retention, which may be a sign of more serious side effects such as heart failure or severe hypertension. It requires prompt medical attention to prevent further complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock?

Correct Answer is C

Explanation

The nurse is providing discharge instructions to a client with gout in the left great toe who received a prescription for prednisone 30 mg by mouth to be administered each day. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

Correct Answer is D

Explanation

A school-aged client was recently diagnosed with type 1 diabetes mellitus. Which symptom did the client's parents most likely report?

The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the CLIENT?

A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What intervention(s) should the nurse include in this client's plan of care? Select all that apply.

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.