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."

Answer and Explanation

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

The correct answer is Choice D.

Choice A rationale: It’s normal for a 4-year-old child to ask the same questions repeatedly. This is a part of their learning process as they are trying to understand the world around them. They often ask the same questions to reassure themselves about the consistency and predictability of the world. However, this is not a priority issue compared to the other options.

Choice B rationale: While it’s important for children to have a balanced diet, including green vegetables, it’s also common for children to be picky eaters. Parents can introduce new foods gradually and make meal times fun to encourage children to eat a variety of foods. However, this is not a priority issue compared to the other options.

Choice C rationale: Bedwetting is common in children and can be a part of their development. Most children outgrow bedwetting by the time they start school. However, if the child is stressed or has a medical condition, it could lead to bedwetting. While this could be a concern, it’s not the priority issue in this scenario.

Choice D rationale: A change in behavior, such as becoming withdrawn, can be a sign of emotional distress in a child. This could be due to a variety of reasons, including changes in their environment like switching day care providers. This is the priority for the nurse to address as it could indicate that the child is having difficulty adjusting to the new day care, which could impact their emotional well-being.

A. Tell the APS to stop the conversation. B. Document the event in the client's progress notes. C. Inform the client of the APs' actions. D. Submit an incident report to the risk manager.

Correct Answer is A

Explanation

A. Correct. Overhearing private client information being discussed by staff members violates the client's right to privacy and confidentiality. The nurse should address the situation immediately and instruct the assistive personnel to stop the conversation.
B. Incorrect. While documenting the event in the client's progress notes may be necessary, addressing the inappropriate behavior of the assistive personnel takes precedence.
C. Incorrect. Informing the client about the conversation is not necessary and may further compromise the client's sense of privacy.
D. Incorrect. Submitting an incident report to the risk manager might be necessary, but the immediate action should be to stop the conversation and address the breach of confidentiality.

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A nurse is providing change of shift report for a client. Which of the following information should the nurse include in the report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?

Correct Answer is D

Explanation

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Correct Answer is A

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