A nurse is giving a change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?
Plan of care changes for the upcoming shift
Intracranial pressure readings
Glasgow results
Code status
The Correct Answer is D
Choice A reason: Plan of care changes for the upcoming shift
Plan of care changes for the upcoming shift are typically included in the “Recommendation” segment of SBAR. This section focuses on what actions need to be taken next, including any changes in the care plan that the oncoming nurse should be aware of. It ensures that the incoming nurse knows what to expect and what specific tasks or interventions are required during their shift.
Choice B reason: Intracranial pressure readings
Intracranial pressure (ICP) readings are crucial for monitoring a client with a traumatic brain injury. However, these readings are more appropriately included in the “Assessment” segment of SBAR. The assessment section provides an analysis of the client’s current condition, including vital signs, lab results, and other critical data. This information helps the oncoming nurse understand the client’s current status and any immediate concerns.
Choice C reason: Glasgow results
The Glasgow Coma Scale (GCS) results are used to assess the level of consciousness in clients with brain injuries. These results should also be included in the “Assessment” segment of SBAR. The GCS score provides valuable information about the client’s neurological status and helps guide clinical decisions. Including this information in the assessment ensures that the oncoming nurse has a clear understanding of the client’s current condition.
Choice D reason: Code status
Code status is a critical piece of information that should be included in the “Background” segment of SBAR. The background section provides relevant clinical history and context for the current situation. Knowing the client’s code status (e.g., full code, do not resuscitate) is essential for making informed decisions about their care, especially in emergency situations. Including this information in the background ensures that the oncoming nurse is aware of the client’s preferences and legal directives.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Wiping from back to front is incorrect and can lead to contamination of the urine sample with bacteria from the anal area. The correct method is to wipe from front to back to reduce the risk of contamination.
Choice B reason:
Urinating a small amount in the toilet before collecting the sample is the correct procedure for obtaining a midstream urine specimen. This helps to flush out any bacteria or contaminants from the urethra, ensuring that the sample collected is as clean as possible.
Choice C reason:
Letting the urine cool to room temperature before sending it to the lab is incorrect. Urine samples should be sent to the lab as soon as possible after collection to ensure accurate results. If there is a delay, the sample should be refrigerated.
Choice D reason:
It is generally recommended to avoid collecting a urine sample during menstruation, as menstrual blood can contaminate the sample and affect the test results.
Correct Answer is B
Explanation
Choice A reason: Tamoxifen
Tamoxifen is a medication primarily used to treat breast cancer. It works as a selective estrogen receptor modulator (SERM), which means it blocks estrogen receptors in breast tissue. Estrogen can promote the growth of breast cancer cells, so blocking its effects can help to slow or stop the growth of these cells. However, tamoxifen is not typically used for prostate cancer because prostate cancer is driven by androgens (male hormones) rather than estrogens.
Choice B reason: Leuprolide
Leuprolide is a medication commonly used in the treatment of prostate cancer. It is a type of hormone therapy known as a luteinizing hormone-releasing hormone (LHRH) agonist. Leuprolide works by reducing the production of testosterone, a hormone that can stimulate the growth of prostate cancer cells. By lowering testosterone levels, leuprolide helps to slow the progression of prostate cancer and can be used in various stages of the disease.
Choice C reason: Finasteride
Finasteride is a medication used to treat benign prostatic hyperplasia (BPH) and male pattern baldness. It works by inhibiting the enzyme 5-alpha-reductase, which converts testosterone to dihydrotestosterone (DHT). While finasteride can reduce the size of the prostate and improve urinary symptoms in BPH, it is not typically used as a primary treatment for prostate cancer. Its role in prostate cancer is more preventive, as it can lower the risk of developing the disease.
Choice D reason: Cyclophosphamide
Cyclophosphamide is a chemotherapy drug used to treat various types of cancer, including lymphomas, leukemias, and some solid tumors. It works by interfering with the DNA of cancer cells, preventing them from dividing and growing. While cyclophosphamide can be used in certain cancer treatments, it is not a standard treatment for prostate cancer. Prostate cancer is more commonly treated with hormone therapy, targeted therapy, or other specific chemotherapy agents.
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