A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation.
When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
Client's healthcare power of attorney.
Fall at home as reason for admission.
Currently prescribed medications.
Increasing confusion of the client.
Increasing confusion of the client.
The Correct Answer is D
Choice A rationale:
Providing information about the client's healthcare power of attorney is not the most critical piece of information to report in this situation. The immediate concern is the client's change in mental status and potential medical emergency.
Choice B rationale:
While the reason for the client's admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client's acute change in mental status.
Choice C rationale:
The nurse should be aware of the client's currently prescribed medications, but this information does not take precedence over the client's sudden onset of confusion and agitation. Immediate action is needed to address the client's altered mental status.
Choice D rationale:
Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client's immediate needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Washing the patient's left side first and then moving to the right side does not demonstrate an individualized approach or consideration for the patient's preferences and abilities. It is important to involve the patient in the decision-making process, especially when they have hemiparesis, to promote their autonomy and comfort.
Choice B rationale:
Washing the patient's right side first and then moving to the left side does not consider the patient's preference and may not align with their abilities or comfort. It is essential to prioritize the patient's preferences and needs.
Choice C rationale:
Washing both sides of the patient at the same time, starting from the head and moving down, may not be feasible or comfortable for the patient, especially if they have hemiparesis. This approach does not demonstrate an individualized care plan based on the patient's specific condition.
Choice D rationale:
Asking the patient which side they prefer to wash first and then following their preference is the most patient-centered and appropriate approach. This approach respects the patient's autonomy and ensures that their needs and comfort are prioritized during the bathing process. It allows for individualized care based on the patient's abilities and preferences.
Correct Answer is B
Explanation
Choice A rationale:
Assisting in discharging stable clients to home is not the most appropriate assignment when a mass casualty event has occurred. During such events, resources are needed for critically injured patients, and stable clients can typically be discharged by non-emergency staff.
Choice B rationale:
Determining the acuity and number of casualties arriving at the facility is the most appropriate assignment during a mass casualty event. This information is critical for allocating resources and providing the necessary level of care to those affected.
Choice C rationale:
Delegating tasks to emergency healthcare specialists may be necessary, but it is not the initial assignment for the nurse working on a medical-surgical unit. Assessing the situation and determining the acuity of incoming casualties take precedence.
Choice D rationale:
Providing informational updates to members of the media is not the role of a nurse during a mass casualty event. This task should be handled by hospital public relations or designated spokespersons to ensure accurate and controlled information dissemination.
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