An older adult client with a history of heart failure is admitted to the medical unit after falling at home and has become increasingly confused. The client's spouse is designated as the client's power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

Fall at home as the reason for admission.

Increasing confusion of the client.

Client's healthcare power of attorney.

Currently prescribed medications.

Answer and Explanation

The Correct Answer is B

Choice A reason: While the fall is important, it is not the most immediate concern for the healthcare provider in the context of SBAR communication.

Choice B reason: Increasing confusion can indicate a change in the client's condition and may require immediate intervention, making it the priority in SBAR communication.

Choice C reason: The client's healthcare power of attorney is important for legal and consent purposes but is not the first piece of information to provide in an SBAR report.

Choice D reason: Currently prescribed medications are part of the background information and would follow after the immediate situation has been described.

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Correct Answer is C

Explanation

Choice A reason: While new management's expectations are important, they are not as immediate a concern as job security during restructuring.

Choice B reason: Changes in job descriptions can be a concern, but they are secondary to the more pressing issue of whether employees will retain their jobs.

Choice C reason: Job security is typically the most pressing concern for employees during restructuring, as it directly impacts their livelihood and future with the company.

Choice D reason: Potential changes in employee benefits are important but are generally less immediate than concerns about job security.

A. Encourage the client to lie as still as possible during the assessment. B. Ask the client how often episodes of sundowning are experienced. C. Assist the client with values clarification about end-of-life care options. D. Question the client about the frequency of falls in recent months.

Correct Answer is D

Explanation

Choice A reason: Encouraging the client to lie still during the assessment is not advisable as it does not provide an accurate representation of the client's functional abilities and needs during rehabilitation.

Choice B reason: While understanding episodes of sundowning can be part of a comprehensive assessment, it is not the action the nurse should implement during a functional assessment aimed at determining the client's physical capabilities.

Choice C reason: Assisting with values clarification about end-of-life care options is important but is not the primary focus of a functional assessment in a rehabilitation setting.

Choice D reason: Questioning the client about the frequency of falls is crucial as it helps assess the risk of future falls and the need for interventions to prevent them, which is a key component of functional assessments in rehabilitation settings.

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Naxlex Comprehensive Predictor Exams

The nurse manager is involved in agency restructuring. During this reengineering process, it is most important for the nurse to address which employee concern?

Correct Answer is C

Explanation

An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

Correct Answer is D

Explanation

After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Patient Data Exhibits Which interventions are indicated to promote positive outcomes for the patient? Select all that apply.

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

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