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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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Monitoring leukocytes, neutrophils, and thyroxine is not the most crucial for a patient with end-stage renal disease (ESRD). While these lab values can provide information about the patient’s immune function and thyroid function, they do not directly relate to the patient’s renal function.
Choice B rationale
Monitoring serum potassium, calcium, and phosphorus levels is crucial for a patient with ESRD. These electrolytes are typically excreted by the kidneys, and their levels can become imbalanced in patients with ESRD. Imbalances can lead to serious complications, such as cardiac arrhythmias and bone disease.
Choice C rationale
Monitoring erythrocytes, hemoglobin, and hematocrit is important for a patient with ESRD, as these patients often develop anemia due to decreased erythropoietin production by the kidneys. However, these are not the only lab values that should be monitored in these patients.
Choice D rationale
Monitoring blood pressure, heart rate, and temperature is important for all patients, but these are not specific to patients with ESRD. Patients with ESRD are at risk for electrolyte imbalances, which can affect cardiac function, making monitoring of serum potassium, calcium, and phosphorus levels more crucial.
Correct Answer is A
Explanation
Choice A rationale
Histamine H2-receptor antagonists, also known as H2 blockers, are medications that help reduce the production of gastric acid. They achieve this by blocking H2 receptors in the parietal cells of the stomach, which are responsible for secreting hydrochloric acid (HCl)12. This reduction in acid secretion can help treat conditions such as peptic ulcers, gastroesophageal reflux disease (GERD), and Zollinger-Ellison syndrome, which are all conditions that can be exacerbated by excessive stomach acid.
Choice B rationale
While H2 blockers do help manage the symptoms of peptic ulcer disease, they do not directly destroy the microorganisms causing inflammation in the stomach. The primary cause of peptic ulcers is a bacterium called Helicobacter pylori, and the treatment for an H. pylori infection typically involves a combination of antibiotics and proton pump inhibitors, not H2 blockers.
Choice C rationale
H2 blockers do not neutralize hydrochloric acid (HCl) in the stomach. Instead, they work by reducing the amount of acid produced by the stomach. Antacids, not H2 blockers, are the class of drugs that work by neutralizing stomach acid.
Choice D rationale
H2 blockers do not inhibit the action of acetylcholine by blocking parasympathetic nerve endings. Anticholinergic medications are the ones that work by blocking the action of acetylcholine, a neurotransmitter that transmits signals in the nervous system.
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