A male client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admission to the medical unit. The family requests an update on the client's condition. Using the SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
Increasing confusion of the client.
Client's healthcare power of attorney.
Currently prescribed medications.
Fall at home as reason for admission.
The Correct Answer is A
Choice A Reason: This is the best action because it describes the current situation of the client and alerts the family to a possible change in the client's status. The nurse should provide the most relevant and urgent information first using the SBAR communication.
Choice B Reason: This is not the first action because it does not address the current situation of the client. The nurse should verify the client's healthcare power of attorney, but this is not a priority at this time.
Choice C Reason: This is not the first action because it does not explain the cause of the client's confusion. The nurse should review the client's medications and assess for any adverse effects, but this is not a priority at this time.
Choice D Reason: This is not the first action because it provides background information that is not directly related to the current situation of the client. The nurse should give a brief history of the client's admission, but this can be done later.
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Related Questions
Correct Answer is C
Explanation
A) This intervention is not the best because it may take too much time and energy from the nurse, who needs to focus on the client's critical condition. The nurse may also have to repeat the same information multiple times, which can be frustrating and confusing for both the nurse and the family.
B) This intervention is not the best because it may not be feasible or appropriate at this time. The healthcare provider may be busy with other clients or procedures, and may not be able to speak with the family right away. The healthcare provider may also need to obtain the client's consent or permission before disclosing any information to the family, which may not be possible if the client is sedated.
C) This intervention is the best because it can help reduce the number and frequency of questions, and facilitate clear and consistent communication between the nurse and the family. The nurse can ask the family to choose one person who will act as their representative and spokesperson, and who will relay any information or updates to the rest of the family. This can also help respect the client's privacy and confidentiality, and prevent any conflicting or contradictory messages.
D) This intervention is not the best because it may not address the family's informational needs or preferences. The chaplain on call may provide spiritual or emotional support to the family, but may not be able to answer any medical or technical questions. The family may also have different religious or cultural beliefs that may not align with the chaplain's role or perspective.
Correct Answer is B
Explanation
Choice A Reason: Waiting until the end of the second week to see if the orientee is able to complete her assignments is not the best action for the charge nurse to take. This would delay providing feedback and support to the orientee, who may feel frustrated and discouraged by her performance. The charge nurse should intervene as soon as possible to help the orientee improve her skills and confidence.
Choice B Reason: Assigning the orientee to work with an experienced nurse who is a long-time, efficient employee is the best action for the charge nurse to take. This would provide the orientee with a role model and a mentor who can guide her through the daily tasks, share tips and tricks, and offer constructive feedback and encouragement. The orientee would benefit from learning from someone who has mastered the workflow and expectations of the unit.
Choice C Reason: Informing the supervisor that for client safety this nurse should be assigned to a slower-paced unit is not the best action for the charge nurse to take. This would imply that the orientee is incompetent and unsuitable for the unit, which may damage her self-esteem and motivation. The charge nurse should first try to help the orientee adjust to the unit and develop her competencies before considering a transfer.
Choice D Reason: Talking to the orientee and asking her if she has considered working in a less stressful environment is not the best action for the charge nurse to take. This would suggest that the charge nurse has given up on the orientee and does not believe in her potential. The charge nurse should first try to understand the challenges and needs of the orientee and provide appropriate guidance and support before suggesting alternative career options.
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