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 D

Explanation

A. Provide high protein snacks. High protein snacks may exacerbate the symptoms of CKD by increasing urea and creatinine levels further. It is not recommended.
B. Administer PRN oxygen. Oxygen therapy is not indicated based on the symptoms described and the laboratory findings of elevated BUN and serum creatinine.
C. Monitor glucose levels every 4 hours. Monitoring glucose levels is not directly related to the symptoms described or the laboratory findings associated with CKD.
D. Schedule frequent rest periods. Fatigue and difficulty concentrating are common symptoms of CKD due to the buildup of waste products in the blood. Scheduling frequent rest periods can
help alleviate these symptoms and improve the client's overall well-being.

A. Provide a flexible activity schedule. B. Provide high-calorie nutritional supplements. C. Allow the client to eat meals alone in her room. D. Allow the client to choose her clothes independently.

Correct Answer is A

No explanation

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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?

Correct Answer is A

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock?

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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?

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