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A nurse is preparing a client for transfer to another unit. Which of the following findings should the nurse include in the transfer report? (Select all that apply.)

Observations about family relationships

Response to pain medication

Review of ongoing discharge plan

Recent physical changes

Comprehensive demographic information

Answer and Explanation

Correct Answer : B,C,D

A. Observations about family relationships: Personal relationship details are not required unless relevant to care.

B. Response to pain medication: Pain management effectiveness is crucial for continuity of care.

C. Review of ongoing discharge plan: The receiving unit should be aware of discharge plans to provide appropriate care.

D. Recent physical changes: Any changes in condition must be reported for safe care continuation.

E. Comprehensive demographic information: Basic demographic details are in the medical record and do not need to be included in a verbal report.

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Correct Answer is D

Explanation

A. Numerical pain scale. Clients with dementia often have difficulty understanding and using numerical pain scales.

B. Verbal description. Many clients with dementia have impaired verbal communication, making it difficult to describe pain effectively.

C. FACES pain scale. While this scale is useful for some nonverbal populations, it still requires the client to actively choose a face, which may be difficult for those with advanced dementia.

D. Behavioral indicators. Observing facial expressions, body movements, vocalizations, and changes in vital signs can help assess pain in clients who cannot self-report. The PAINAD (Pain Assessment in Advanced Dementia) scale is commonly used.

A. Document shiny, taut skin as an expected finding. B. Perform palpation after auscultation. C. Listen for 1 min before documenting absent bowel sounds. D. Perform auscultation immediately after the client has consumed a meal.

Correct Answer is B

Explanation

A. Document shiny, taut skin as an expected finding. Shiny, taut skin may indicate ascites or fluid retention, which are abnormal findings.

B. Perform palpation after auscultation. Palpation should always follow auscultation to avoid altering bowel sounds.

C. Listen for 1 min before documenting absent bowel sounds. Bowel sounds are considered absent only after listening for at least 5 minutes in each quadrant.

D. Perform auscultation immediately after the client has consumed a meal. Post-meal auscultation may result in altered bowel sounds, making the assessment unreliable.

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A nurse is preparing a client for transfer to another unit. Which of the following findings should the nurse include in the transfer report? (Select all that apply.)

Nursing Test Bank

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