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 C
Explanation
The client with Addison's disease is experiencing weakness, confusion, and dehydration, which can be indicative of an adrenal crisis. The low sodium level (129 mEq/L) and low glucose level (54 mg/dl) further support this suspicion. An acute viral infection can trigger an adrenal crisis in individuals with Addison's disease.
Intravenous hydrocortisone, a glucocorticoid, is the treatment of choice for managing an adrenal crisis. It helps to replenish cortisol levels and stabilize the client's condition.
Hydrocortisone helps in restoring the body's stress response and regulating electrolyte and glucose levels.
A broad-spectrum antibiotic may be necessary if there is evidence of a bacterial infection, but it does not directly address the symptoms associated with Addison's disease.
Regular insulin is used for managing high blood glucose levels in conditions such as diabetes, but in this case, the client has low glucose levels, so insulin is not the appropriate intervention.
Potassium chloride is a medication used to treat low potassium levels (hypokalemia), but the client's potassium level is within the reference range (5.3 mEq/L). Therefore, potassium chloride is not indicated in this situation.
Correct Answer is A
Explanation
The presenting symptoms of the infant, including persistent vomiting, poor skin turgor, significant weight loss, and a palpable abdominal mass, indicate a potential serious condition that requires immediate attention. These findings may suggest dehydration, malnutrition, and the presence of an abdominal mass that could be causing gastrointestinal obstruction or other underlying pathology.
Initiating a prescribed IV for parenteral fluid is the priority intervention to address the potential dehydration and fluid imbalance in the infant. This will help restore and maintain adequate hydration while further diagnostic evaluations and interventions are initiated.
Feeding the infant, giving 5% dextrose in water orally, or inserting a nasogastric tube for feeding should not be implemented as the first intervention in this case. It is important to stabilize the infant's fluid status before initiating oral feedings or other interventions to address the underlying cause of the symptoms.
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