A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?
"The client has developed drooping facial features."
"The client may benefit from a neurology consult."
"The client is disoriented and pupils are slow to respond to light."
"The client has a history of hypertension."
The Correct Answer is D
Explanation:
A. "The client has developed drooping facial features."
This statement provides specific information about a recent change in the client's condition, which is relevant background information. It helps the provider understand one of the key reasons for the communication.
B. "The client may benefit from a neurology consult."
While suggesting a neurology consult is a potential recommendation (R) in the SBAR tool, it is not part of the Background (B) component. Background information typically focuses on factual data about the client's history, current condition, and pertinent details relevant to the situation.
C. "The client is disoriented and pupils are slow to respond to light."
Similar to option B, this statement describes the client's assessment findings and current condition rather than providing background information. It would be more appropriate in the Assessment (A) component of the SBAR tool.
D. "The client has a history of hypertension."
This statement provides relevant background information about the client's medical history, specifically their history of hypertension. Including this information in the Background component helps the provider understand the client's baseline health status, which is important for evaluating the current situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Explanation:
A. Incorporate the treatment into the client's care:
Once the nurse has determined whether the client's grieving is healthy or complicated, they can integrate appropriate treatments and interventions into the client's care plan. Treatment options may include counseling, therapy, support groups, medication (if indicated), and holistic approaches to address physical, emotional, and spiritual aspects of grief.
B. Develop client-specific goals and outcomes:
Collaborating with the client, the nurse establishes client-specific goals and outcomes related to grief management and coping. These goals should be realistic, measurable, and aligned with the client's needs and preferences. Examples of goals may include improving coping skills, reducing emotional distress, fostering acceptance, and promoting resilience.
C. Determine whether coping strategies were successful:
Throughout the care process, the nurse continuously evaluates the effectiveness of coping strategies implemented to support the client in managing grief. Assessment of coping strategies involves monitoring the client's emotional state, functional status, coping skills utilization, and progress toward achieving established goals and outcomes. Adjustments to the care plan may be made based on the assessment findings.
D. Establish whether the client's grieving is healthy or complicated:
This step involves assessing the client's grief to determine whether it is a normal, healthy response to loss or if it has become complicated, characterized by intense, prolonged, or dysfunctional grief reactions. Assessing the client's grief status is crucial for tailoring appropriate interventions and support.
Correct Answer is C
Explanation
A.While childhood obesity is a health concern, it is not a specific indicator of abuse. Obesity can result from dietary habits, lack of physical activity, or medical conditions.
B.Fear of injections is common in children and is a typical developmental response. Crying during an injection is not an indicator of abuse and is expected behavior for many children.
C.While this finding alone does not confirm abuse, it may indicate an underlying issue in the adolescent's home environment. It requires further exploration through careful, open-ended questioning to assess for potential emotional or physical abuse or neglect.
D.Bruising on the shins of toddlers is common due to normal play and falls during development. The explanation provided by the parents aligns with typical toddler behavior and does not raise immediate concerns for abuse unless the bruises are in unusual locations (e.g., abdomen, back, or thighs).
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