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 reports pain is reduced when he is positioned on his side."
"The client received the prescribed antibiotic every 8 hours."
"The client's mother died 4 years ago from breast cancer."
"The client's partner visited earlier today for 2 hours."
The Correct Answer is A
A. Correct. Providing information about the client's pain relief strategies and positioning preferences helps ensure continuity of care and optimal comfort for the client.
B. Incorrect. While medication administration is important, it's not as relevant for the change of shift report as information related to the client's condition, preferences, and care needs.
C. Incorrect. The client's family history of breast cancer is not the most critical information for the immediate care of the client and can be discussed during a more comprehensive assessment.
D. Incorrect. Although family support and visits are important, the duration of the partner's visit is not as relevant as the client's immediate care needs and preferences.
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Correct Answer is D
Explanation
A. Incorrect. Instructing the client to take a brisk walk might exacerbate their symptoms.
B. Incorrect. Checking the client's temperature is not indicated based on the reported symptoms.
C. Incorrect. Providing orange juice might help with low blood sugar but doesn't directly address the reported symptoms.
D. Correct. Positioning the client on their left side can improve blood flow to the heart and uterus, alleviating symptoms of dizziness and racing heart that can occur due to pressure on the vena cava when lying flat on the back.
Correct Answer is ["B","E"]
Explanation
A. Vertigo is common after inner ear surgery like stapedectomy and can be related to changes in the inner ear. It should be monitored, but it's not an immediate concern unless severe.
B. Correct. A change in facial symmetry (left facial droop) is indicative of potential facial nerve dysfunction, which requires immediate attention.
C. Pupils are reactive to light, and their size is within the expected range, indicating normal pupillary function.
D. A pain rating of 5 on a scale of 0 to 10 indicates moderate pain. While it requires attention, it's not a critical concern.
E. Correct. Diminished hearing following ear surgery is an expected finding, but the nurse should assess the degree and type of hearing loss and communicate this to the healthcare provider.
F. Lung assessment is important but does not require immediate action based on the given information.
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