A patient is brought to the emergency department after falling from a ladder and is exhibiting signs of confusion and disorientation.
The spouse reports that the patient seemed to have lost consciousness.
The nurse has been provided with a list of current medications and healthcare power of attorney.
When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
The patient’s currently prescribed medications.
The increasing confusion of the patient.
The patient’s healthcare power of attorney.
The fall from a ladder as the reason for admission.
The Correct Answer is D
Choice A rationale
While it’s important to know the patient’s current medications as they can influence the patient’s condition and treatment plan, this information is not the most critical to convey first in this situation.
Choice B rationale
The increasing confusion of the patient is a significant symptom, especially after a fall. It could indicate a possible head injury. However, the cause of the confusion (the fall) should be communicated first.
Choice C rationale
Knowing who holds the patient’s healthcare power of attorney is important, especially if the patient’s condition worsens and decisions need to be made on their behalf. However, this information is not the most critical to convey first.
Choice D rationale
The fall from a ladder as the reason for admission is the most important information to provide first. This gives the healthcare provider immediate context about the potential severity and type of injuries, guiding further assessment and treatment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Suggesting that the child participate in a team sport to encourage socialization is not the best response. Duchenne muscular dystrophy (DMD) is a progressive disease that causes muscle weakness and loss of muscle mass. Participating in a team sport could be physically challenging for the child and could potentially lead to injury.
Choice B rationale
Encouraging the parents to allow the child to continue attending swimming lessons with supervision is the best response. Swimming is a low-impact exercise that can help maintain muscle strength and flexibility in children with DMD. It also provides an opportunity for socialization.
Choice C rationale
Explaining that the child is too young to understand the risks associated with swimming is not the best response. Children with DMD can participate in swimming with appropriate supervision and safety measures in place.
Choice D rationale
Providing a list of alternative activities that are less likely to cause the child to experience fatigue is not the best response. While it’s important to consider activities that are appropriate for the child’s physical abilities, it’s also important to consider the child’s interests. The child has expressed a desire to continue swimming, and with appropriate supervision, this activity can be beneficial.
Correct Answer is D
Explanation
Choice A rationale
While switching to less anxiety-provoking questions might help in some situations, it does not address the immediate issue of the client undressing inappropriately.
Choice B rationale
Ignoring the client’s inappropriate behavior could potentially encourage further inappropriate actions and does not respect the therapeutic boundaries necessary in a nurse-client relationship.
Choice C rationale
Leaving the client’s room might escalate the situation further and does not address the immediate issue.
Choice D rationale
The nurse should assertively but respectfully communicate that undressing is not appropriate during the interview. This sets clear boundaries and expectations for the client’s behavior.
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