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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.2"]
Explanation
Step-by-step Calculation:
- We need to find the volume (in mL) of teriparatide that contains the desired dose of 60 mcg.
- Set up the proportion:dose (mcg) / concentration (mcg/mL) = volume (mL)
- Fill in the known values:
- Dose (mcg): 60 mcg (as given in the problem)
- Concentration (mcg/mL): 750 mcg/2.4 mL (from the medication label)
- Solve for the volume:
- Multiply both sides of the proportion by the concentration to isolate the volume on the left:
- dose (mcg) = volume (mL) concentration (mcg/mL)
- Substitute the known values:
- 60 mcg = volume (mL) (750 mcg / 2.4 mL)
- Calculate the volume:
-
- Divide both sides by the concentration to solve for the volume:
- volume (mL) = 60 mcg / (750 mcg / 2.4 mL)
- Simplify:
- volume (mL) = (60 mcg 2.4 mL) / 750 mcg
- volume (mL) = 0.192 mL (approximately)
- Rounding (optional): The problem specifies rounding to the nearest tenth. Since 0.192 is closer to 0.2 than 0.1, the rounded volume is:
- volume (mL) = 0.2 mL (rounded to one decimal place)
Therefore, the nurse should administer 0.2 mL of teriparatide.
Correct Answer is D
Explanation
A. Resume antithyroid drug therapy.
Antithyroid medications are typically not resumed immediately post-thyroidectomy unless specifically directed by the healthcare provider. The focus post-surgery is often on managing potential complications and ensuring proper healing.
B. Anticipate and monitor for hypothermia.
Hypothermia is not a common concern following thyroidectomy. The nurse should monitor for other more relevant complications such as bleeding, airway obstruction, and hypocalcemia.
C. Prepare to administer radioactive iodine treatments.
Radioactive iodine treatment is usually not administered immediately post-thyroidectomy. It may be considered later, depending on the reason for the thyroidectomy and the individual treatment plan.
D. Maintain a semi-Fowler position.
This is the correct intervention. Maintaining the client in a semi-Fowler position helps reduce strain on the surgical site, facilitates breathing, and minimizes the risk of complications such as bleeding and edema in the neck area. It is an essential part of postoperative care for
thyroidectomy patients.
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