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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. The bedside table should be within easy reach of the bed to prevent the client from attempting to reach for items and potentially falling.
B. Correct. Moving the client's bed to the main floor of the house reduces the need for using stairs, which can be a fall risk for clients at risk for falls.
C. Incorrect. Keeping the lighting dim increases the risk of falls. Adequate lighting is important to prevent falls.
D. Incorrect. Area rugs on slick floor surfaces can be hazardous and increase the risk of falls.
They should be removed or secured properly.
Correct Answer is ["A","B","C","E","F","G","H"]
Explanation
A.Caffeine can exacerbate symptoms of mania by increasing restlessness and irritability. Avoiding caffeine can help in managing these symptoms.
B.Lithium is a common medication used to manage manic episodes in bipolar disorder. Monitoring lithium levels is crucial to ensure the client's safety and therapeutic effectiveness.
C.Clients experiencing mania may have difficulty focusing and completing tasks, including personal hygiene. Step-by-step reminders can help the client maintain proper hygiene.
D.While social interaction can be beneficial, clients in a manic state may become overstimulated or disruptive in group settings. Individual activities are often more appropriate until the mania is better controlled.
E.Clients in a manic state may be too restless to sit down for meals. Offering finger foods allows them to eat while on the go, helping to maintain adequate nutrition.
F.Clients with mania may exhibit aggressive behaviors. Redirecting these behaviors to safer or more appropriate outlets is important for the safety of the client and others.
G.The client's vital signs indicate an increase in heart rate and blood pressure, which are important to monitor closely as they can be affected by the heightened physical activity and agitation associated with mania.
H.Lithium can cause fluid retention and weight gain. Daily weight monitoring helps detect sudden increases that may indicate fluid imbalance or early signs of lithium toxicity. It also assists in managing and adjusting treatment as needed to prevent complications.
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