A nurse is providing change-of-shift report to another nurse for a client using the Introduction, Situation, Background, Assessment and Recommendation (ISBARR) communication tool. Which of the following information should the nurse include as part of the situation component of this communication tool?

Medical condition

Treatment

Vital signs

List of medications

Answer and Explanation

The Correct Answer is A

Explanation:

A. Medical condition:

Including the client's medical condition in the Situation component of the ISBARR communication tool is important because it provides an overview of the client's health status. This may include a brief description of the primary diagnosis, current symptoms, or any significant changes in the client's condition since the last shift. It helps the receiving nurse understand the context and urgency of the report.

B. Treatment:

While treatment information is crucial for providing comprehensive care to the client, it is typically included in the Background or Assessment components of the ISBARR communication tool. The Situation component focuses on summarizing the client's current status rather than detailing specific treatments or interventions.

C. Vital signs:

Vital signs, such as heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation, are essential clinical data. However, they are usually included in the Assessment component of the ISBARR communication tool, where the nurse provides a detailed assessment of the client's physiological parameters and trends.

D. List of medications:

Similar to treatment information, a list of medications is typically included in the Background or Assessment components of the ISBARR communication tool. It is important for the receiving nurse to know what medications the client is taking, including doses, frequencies, and any recent changes, but this information is more detailed and specific than what is typically included in the Situation component.

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Correct Answer is D

Explanation

Explanation:

A. "I promise I won't tell anyone about this."

This statement is not appropriate because nurses are mandated reporters of suspected child abuse. Promising confidentiality in cases of abuse goes against legal and ethical responsibilities. The nurse must report suspected abuse to the appropriate authorities for the safety and well-being of the child.

B. "Your family is bad for doing this to you."

This statement is judgmental and may make the child feel guilty or conflicted about their family. It is essential to avoid blaming or shaming language when addressing a child who has been abused. The focus should be on providing support, validation, and appropriate intervention.

C. "Let's discuss what you have told me with your family members."

This statement is not appropriate because it suggests involving the family members in the discussion of abuse, which can potentially put the child at risk of further harm. It's essential to prioritize the safety of the child and follow appropriate reporting procedures rather than involving potentially abusive family members in discussions about abuse.

D. "It is not your fault that this happened."

This statement is appropriate and supportive. It reassures the child that they are not to blame for the abuse they have experienced. It acknowledges the child's feelings and helps them understand that they are not responsible for the actions of the abuser. This statement can provide comfort and validation to the child during a difficult time.

A. Grab bars are installed in the bathroom. B. Medications are stored in a clear bag. C. Area rugs are placed in the living room. D. Dim lighting installed throughout the house. E. The hot water heater is set at 54°C (130° F).

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

Explanation

A. Grab bars are installed in the bathroom:

Correct placement of grab bars in the bathroom can enhance safety for individuals who have mobility challenges, such as those who have experienced a stroke. This is not a safety hazard but rather a safety measure.

B. Medications are stored in a clear bag:

Storing medications in a clear bag may increase the risk of accidental misuse or confusion, particularly for a stroke client who may have cognitive or visual impairments.

C. Area rugs are placed in the living room:

Area rugs can be a safety hazard, especially for individuals with mobility issues or those at risk of falls. Rugs can cause tripping hazards if they are not properly secured or if there are wrinkles or uneven surfaces.

D. Dim lighting installed throughout the house:

Dim lighting can contribute to safety hazards, particularly for individuals with visual impairments or mobility challenges. Insufficient lighting increases the risk of falls and accidents, especially in areas such as staircases, hallways, and bathrooms.

E. The hot water heater is set at 54°C (130° F):

Water temperature set at 54°C (130° F) is excessively hot and poses a scalding hazard, especially for individuals with sensory impairments or reduced ability to perceive temperature changes. Lowering the water heater temperature to a safer range is recommended to prevent scalding injuries.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who reports being physically abused by a family member. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for them? (Select All that Apply.)

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

Explanation

A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?

A nurse is reinforcing teaching with a newly licensed nurse regarding sources of medication information. Which of the following resources should the nurse include as reliable references for the nurse to use to evaluate medication information? (Select all that apply.)(Select All that Apply.)

A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse should identify which of the following as one of the five rights of delegation?

A nurse is preparing to administer amoxicillin 500 mg PO. Available is amoxicillin 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of SBAR?

A nurse on a medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse that one of the children is a potential victim of abuse?

A nurse is reinforcing teaching about delegation with a newly licensed nurse. Which of the following statements if made by the newly licensed nurse indicates understanding?