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 A
Explanation
Explanation:
A. Right communication:
This refers to providing clear and concise instructions to the assistive personnel regarding the delegated task. Effective communication ensures that the AP understands the task, its objectives, any limitations or special considerations, and the expectations regarding its completion. Clear communication helps prevent misunderstandings and promotes safe and efficient task execution.
B. Right room:
This choice does not directly relate to the five rights of delegation. The "right room" concept may refer to ensuring that the environment or room where care is provided is appropriate, safe, and conducive to the task being performed. While environmental factors are important in healthcare, they are not part of the specific rights of delegation.
C. Right time:
The "right time" aspect of delegation involves considering the timing of the task within the overall care plan. It includes assessing whether the task should be performed immediately, at a specific time, or within a particular timeframe. Delegating tasks at the right time ensures that they align with the client's needs and the overall care schedule.
D. Right documentation:
This refers to documenting the delegation process, including details such as the delegated task, the personnel involved, any specific instructions or limitations provided, and the outcomes or results of the task. Documentation is crucial for accountability, continuity of care, and legal purposes, ensuring that there is a record of who performed the task and how it was carried out.
Correct Answer is ["B","C","D","E"]
Explanation
A. Grab bars are installed in the bathroom:
Correct placement of grab bars in the bathroom can enhance safety for individuals who have mobility challenges, such as those who have experienced a stroke. This is not a safety hazard but rather a safety measure.
B. Medications are stored in a clear bag:
Storing medications in a clear bag may increase the risk of accidental misuse or confusion, particularly for a stroke client who may have cognitive or visual impairments.
C. Area rugs are placed in the living room:
Area rugs can be a safety hazard, especially for individuals with mobility issues or those at risk of falls. Rugs can cause tripping hazards if they are not properly secured or if there are wrinkles or uneven surfaces.
D. Dim lighting installed throughout the house:
Dim lighting can contribute to safety hazards, particularly for individuals with visual impairments or mobility challenges. Insufficient lighting increases the risk of falls and accidents, especially in areas such as staircases, hallways, and bathrooms.
E. The hot water heater is set at 54°C (130° F):
Water temperature set at 54°C (130° F) is excessively hot and poses a scalding hazard, especially for individuals with sensory impairments or reduced ability to perceive temperature changes. Lowering the water heater temperature to a safer range is recommended to prevent scalding injuries.
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