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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Referring the client to a social worker for support therapy may be premature at this stage. The client's initial reaction may be due to fear or anxiety about the diagnosis and self-administration of insulin. Pushing the client into therapy without assessing their readiness may not be appropriate.

Choice B rationale:

Encouraging the client to implement relaxation techniques assumes that the client is open to learning and just needs help with anxiety management. However, the client's refusal to have the nurse in the room suggests that they are not currently receptive to teaching. It's important to address the client's emotional state first.

Choice C rationale:

Leaving the client's room and returning later in the day is the most appropriate initial action. The client's loud refusal indicates a need for privacy and emotional space. By respecting the client's wishes and revisiting the teaching later, the nurse can establish trust and build a better rapport.

Choice D rationale:

Explaining that insulin is a life-saving drug is informative but may not be effective in this situation, as the client has already requested the nurse to leave the room. Providing information about the importance of insulin should come after establishing a therapeutic nurse-client relationship.

A. Fresh or frozen vegetables without sauce. B. Fruits without sauce. C. Pickled olives. D. Canned soup. E. Cottage cheese.

Correct Answer is ["A","B"]

Explanation

Choice A rationale:

Fresh or frozen vegetables without sauce. Rationale: Fresh or frozen vegetables without sauce are excellent choices for a client with hypertension. These foods are low in sodium and can help manage blood pressure effectively. The absence of added sauces ensures that there is no hidden sodium content.

Choice B rationale:

Fruits without sauce. Rationale: Fruits without sauce are also suitable for clients with hypertension. They are naturally low in sodium and provide essential nutrients that can support blood pressure control. The absence of sauce ensures that no additional sodium is added.

Choice C rationale:

Pickled olives. Rationale: Pickled olives are high in sodium due to the pickling process. Therefore, they are not recommended for clients with hypertension as they can lead to an increase in blood pressure.

Choice D rationale:

Canned soup. Rationale: Canned soup often contains high levels of sodium, which is not suitable for clients with hypertension. Excessive sodium intake can contribute to elevated blood pressure and should be avoided.

Choice E rationale:

Cottage cheese. Rationale: Cottage cheese is generally considered acceptable for clients with hypertension, especially if it is the low-sodium or reduced-sodium variety. However, it is not as strongly recommended as fresh or frozen vegetables and fruits without sauce.

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Naxlex Comprehensive Predictor Exams

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

Correct Answer is C

Explanation

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? (Select all that apply.).

Correct Answer is ["A","B"]

Explanation

The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) take in this situation?

A nurse is planning recreational activities for a group of patients who are receiving rehabilitation and restorative care. Which of the following factors should the nurse consider when selecting appropriate activities? (Select all that apply.).

A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis. The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements. Which factor is the most likely cause for this problem?

A nurse is providing interventions for a client with panic disorder. Which interventions should the nurse include in the plan of care? (Select all that apply).