A nurse is preparing to provide report on a client using the Situation-Background- Assessment-Recommendation (SBAR) Communication tool.
Identify the order in which the nurse should give report.

Provide a brief description of the client’s diagnosis.

Discuss suggestions for continuing the client’s care.

State the client’s most recent vital signs.

Review the client’s pertinent medical history.

Answer and Explanation

The Correct Answer is B

The nurse should give report using the SBAR Communication tool in the following order: Situation, Background, Assessment, Recommendation. This tool provides a framework for communication between members of the health care team about a patient’s condition. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team.

Choice A is wrong because it is part of the Background section of the SBAR tool, which comes after the Situation section.

Choice C is wrong because it is part of the Assessment section of the SBAR tool, which comes after the Background section.

Choice D is wrong because it is also part of the Background section of the SBAR tool, which comes after the Situation section.

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Correct Answer is ["B","C","E"]

Explanation

Correct Answers:Distractibility. Grandiose thinking. Flight of ideas.

These are the common symptoms of mania in bipolar disorder.

Some possible explanations for the other choices are:

Choice A is wrong because anhedonia, which means loss of interest or pleasure in activities, is a symptom of depression, not mania.
Choice D is wrong because overeating is not a specific symptom of mania, although some people with bipolar disorder may have changes in appetite or weight during mood episodes.

A. A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus. B. A client who is 3 days postpartum and has not had a bowel movement since prior to admission. C. A client who is 4 days postpartum and has lochia serosa. D. A client who is 1 day postpartum and has not voided in 8 hr.

Correct Answer is D

Explanation

A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.

Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.

The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.

Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.

Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.

The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.

Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.

Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.

It consists of old blood, serum, leukocytes, and tissue debris.

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A nurse is preparing to provide report on a client using the Situation-Background- Assessment-Recommendation (SBAR) Communication tool. Identify the order in which the nurse should give report.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has bipolar disorder and is exhibiting manifestations of mania. Which of the following findings should the nurse expect? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

A nurse on a postpartum unit is caring for a group of clients. Which of the following clients is the nurse’s priority?

Correct Answer is D

Explanation

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A nurse is preparing to provide report on a client using the Situation-Background- Assessment-Recommendation (SBAR) Communication tool.
Identify the order in which the nurse should give report.