An older client with a history of heart failure and 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?
Currently prescribed medications.
Fall at home as reason for admission.
Client's healthcare power of attorney.
Increasing confusion of the client.
The Correct Answer is D
Situation: Increasing confusion of the client.
The nurse should start by providing the current situation, which is the client's increasing confusion. This is crucial information as it indicates a change in the client's condition and may require immediate attention.
Background: Fall at home as reason for admission.
Next, the nurse should provide the background information, which includes the reason for admission, in this case, the fall at home. This helps the healthcare provider understand the context and potential contributing factors to the client's current condition. Assessment: Currently prescribed medications.
After providing the background, the nurse should discuss the assessment findings. In this case, it would be appropriate to mention the client's currently prescribed medications. This information can help the healthcare provider assess for any medication-related issues or interactions that could be contributing to the client's confusion.
Recommendation: Client's healthcare power of attorney.
Lastly, the nurse should provide the recommendation, which in this case is the client's healthcare power of attorney. This information is important as it identifies the designated decision-maker for the client's healthcare decisions and can assist the healthcare provider in involving the appropriate person in the care planning process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Assessing and managing pain is a crucial aspect of providing atraumatic care for any post-operative patient, including a child with spastic cerebral palsy. It is important to monitor and assess the child's pain levels regularly to ensure their comfort and
well-being. Pain can be particularly challenging to assess in a child with cognitive and speech delays, so the nurse should use appropriate pain assessment tools and also consider nonverbal cues, changes in behavior, and physiological indicators of pain.
While antibiotics may be prescribed if there is an infection present, it is not mentioned as a priority in this specific scenario. The focus is on providing atraumatic care post-operatively.
Occupational therapy, physical therapy, and wound care are all important components of the child's overall care, but they may not be the immediate priority post-operatively. The child's specific needs and surgical procedure will determine when these interventions are appropriate and can be incorporated into the plan of care as needed. However, addressing pain is of utmost importance in the immediate post-operative period.
Correct Answer is ["B","D"]
Explanation
The age-related factors that may factor into this client's wound healing are: Decreased epidermal turnover: As people age, the turnover of skin cells decreases, resulting in slower wound healing. This can prolong the healing process and increase the risk of complications.
T-cell function decrease: The immune system's function, including T-cell function, tends to decline with age. T-cells play a crucial role in the immune response and wound healing. Decreased T-cell function can impair the body's ability to fight infection and promote efficient healing.
Insulin resistance and pigmentation changes are not directly age-related factors that impact wound healing. Insulin resistance is a condition related to impaired glucose metabolism and can affect wound healing in individuals with diabetes or other metabolic disorders, but it is not necessarily an age-related factor. Pigmentation changes are primarily cosmetic and do not directly affect the physiological processes involved in wound healing.
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