A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?
"The client's partner visited earlier today for 2 hours."
"The client received the prescribed antibiotic every 8 hours."
"The client's mother died 4 years ago from breast cancer."
"The client reports pain is reduced when he is positioned on his side.”
The Correct Answer is D
Rationale:
A. "The client's partner visited earlier today for 2 hours.": While documenting visitors can be relevant in certain psychosocial or safety contexts, this detail is not critical to clinical decision-making or continuity of care during shift handoff.
B. "The client received the prescribed antibiotic every 8 hours.": Routine administration of scheduled medications does not need to be reported unless there are concerns like adverse reactions, missed doses, or changes in therapy. Simply stating adherence to the schedule adds little value to clinical communication.
C. "The client's mother died 4 years ago from breast cancer.": Past family history may be relevant to the medical record, but it does not impact immediate clinical care or require prioritization during a shift change report unless it is directly influencing current treatment decisions.
D. "The client reports pain is reduced when he is positioned on his side.”: This is current, subjective, and actionable information that informs the incoming nurse about effective pain management strategies and contributes to patient comfort and care planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Rationale:
• Seizures: The client’s significantly elevated T3 (230 ng/dL), T4 (3.4 ng/dL), and TSI (150%) levels, along with symptoms such as anxiety, heat intolerance, insomnia, and irritability, suggest hyperthyroidism and risk for thyroid storm. This hypermetabolic state can lead to neurological complications including seizures due to increased cerebral excitability.
• Pneumonia: The client has no respiratory distress, maintains a clear airway, has normal respiratory rate and oxygen saturation, and shows no pulmonary abnormalities. There are no signs to suggest a risk for infection or hypoventilation.
• Paralytic ileus: There are no gastrointestinal symptoms such as abdominal distension, absent bowel sounds, or nausea. The client has normal GI function with a good appetite and soft brown stools, ruling out risk of ileus.
• thyroid storm: The clinical picture unplanned weight loss, exophthalmos, goiter, hyperreflexia (suggested by irritability), and insomnia aligns with Graves’ disease and severe thyrotoxicosis. Surgery can precipitate a thyroid storm if thyroid hormone levels are not well controlled beforehand.
• hypoparathyroidism: While this is a known risk after thyroidectomy due to parathyroid injury, the client has not yet had surgery at the time of the lab results and symptoms. No signs of hypocalcemia (e.g., tingling, cramps) are present either.
• laryngeal nerve damage: This is an intraoperative complication, generally presenting as hoarseness or voice changes. There are no findings suggesting vocal cord involvement, and it would not lead to seizures.
Correct Answer is C
Explanation
Rationale:
A. Alternative care provider: An alternative care provider may offer complementary therapies such as acupuncture or herbal treatments, but they are not specifically trained to assist with functional difficulties related to ADLs.
B. Nutritionist: A nutritionist can help manage diet and nutritional concerns, however, they do not specialize in helping clients adapt to challenges with cooking and eating caused by joint stiffness or pain.
C. Occupational therapist: An occupational therapist specializes in helping individuals adapt to physical limitations that interfere with daily living tasks. They can assess the client's needs and provide strategies, tools, and exercises to enhance independence with activities such as cooking and eating.
D. Dentist: A dentist focuses on oral health and is not involved in helping clients manage limitations in performing ADLs. This referral would be unrelated to the client's current difficulty managing tasks due to rheumatoid arthritis.
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