A client is brought to the emergency department after falling from of a ladder and is showing signs of confusion and disorientation. The spouse states the client appeared to have lost consciousness. The nurse is 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?

Currently prescribed medications.

Falling from a ladder as reason for admission.

Increasing confusion of the client.

Client's healthcare power of attorney.

Answer and Explanation

The Correct Answer is C

A. Currently prescribed medications are important information, but in this emergent situation, the nurse should first report on the client's condition and immediate concerns.

B. Falling from a ladder as the reason for admission is relevant information, but it does not address the immediate clinical concern of the client's altered mental status.

C. Reporting the increasing confusion of the client is the priority as it highlights the acute change in neurological status, which may indicate a more critical issue such as intracranial injury or neurological impairment.

D. The client's healthcare power of attorney is important for long-term care planning, but it is not the immediate concern when the client presents with altered mental status and potential head
trauma.

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Free Nursing Study Resources

Correct Answer is []

Explanation

Immunological Administer antihistamine
The correct answer is to administer antihistamine. Antihistamines can help alleviate symptoms of an allergic reaction, such as itching, hives, and swelling, by blocking the effects of histamine
released during the allergic response.

Cardiovascular

Monitor vital signs continuously

The correct answer is to monitor vital signs continuously. Continuous monitoring of vital signs, including blood pressure, heart rate, and oxygen saturation, is essential to detect any changes in the client's cardiovascular status, especially after experiencing adverse reactions to medication.

Provide warmth

Providing warmth can help improve peripheral circulation and comfort for the client, especially if they are experiencing symptoms such as dizziness or feeling cold due to a drop in blood pressure.

Respiratory

Assess lung sounds

The correct answer is to assess lung sounds. Assessing lung sounds can help determine if the client is experiencing any respiratory distress or complications, such as wheezing or crackles, which may indicate a need for further intervention or respiratory support.

Chest x-ray

Ordering a chest x-ray can help evaluate the client's respiratory status, especially if there are concerns about potential complications such as pneumonia or pulmonary edema. It allows for the assessment of lung fields and can provide valuable information about the client's respiratory function.

A. Listen attentively to the client's description of the event. B. Report the incident to the university's security department. C. Do not allow client to shower until all evidence is obtained. D. Determine the client's personal reaction to the reported rape.

Correct Answer is C

Explanation

A. Listen attentively to the client's description of the event. While important for providing emotional support, it is secondary to preserving forensic evidence.
B. Report the incident to the university's security department. This is necessary but not as immediately critical as preserving evidence.
C. Do not allow client to shower until all evidence is obtained. Preserving evidence is the highest priority in this situation to ensure a thorough forensic investigation and legal process.
D. Determine the client's personal reaction to the reported rape. Understanding the client's emotional state is important for providing support, but it should be done after ensuring that critical forensic evidence is collected.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

The nurse who is working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

The nurse is providing discharge instructions to a client with gout in the left great toe who received a prescription for prednisone 30 mg by mouth to be administered each day. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

The nurse is preparing to administer a narcotic analgesic to a client with a fractured femur who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement?

A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which information reported by the client indicates understanding?

The nurse is preparing a client with breast cancer for BRCA1 and BRCA2 genetic testing. Which pathophysiological process should the nurse use to support client teaching?

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?