A newly licensed nurse is giving a change-of-shift report using Introductions, Situation, Background, Assessment, Recommendation (ISBAR) to an oncoming nurse. Which of the following statements by the newly licensed nurse should be included in the "Background" portion of the report?
"The client has a new prescription for incentive spirometry."
"The client's partner plans to return later today."
"The client has no living family members."
"I initiated a consultation by a nutritionist."
The Correct Answer is C
A. "The client has a new prescription for incentive spirometry.": This statement is more appropriate for the "Assessment" or "Recommendation" section, as it pertains to current treatment plans and interventions rather than the background context of the client's history.
B. "The client's partner plans to return later today.": This information is relevant to the client's social support and engagement but is not critical background information. It may be included in the "Situation" or "Recommendation" sections instead.
C. "The client has no living family members.": This statement is pertinent to the "Background" portion, as it provides important context regarding the client's social situation and support system. Understanding the client's background helps the receiving nurse assess potential psychosocial needs and planning for care.
D. "I initiated a consultation by a nutritionist.": This action relates to ongoing care and assessment of the client's nutritional needs, making it more appropriate for the "Assessment" or "Recommendation" section. It is not part of the historical background needed for effective handoff.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Teach the client about the potential health risks of leaving early: The first action the nurse should take is to inform the client about the potential health risks associated with leaving the facility against medical advice. Providing this information ensures that the client is fully informed about the consequences of their decision, which is essential for promoting their safety and well-being.
B. Ask the client to sign a document stating they are leaving AMA: While obtaining a signed document is necessary, it should occur after the client has been informed about the risks involved in leaving. The nurse should first ensure the client understands the implications of their decision.
C. Document the client's statement in direct quotes in the medical record: Documentation is important but should not be the first action taken. The nurse must first address the client’s immediate request and provide information regarding potential health risks before focusing on documentation.
D. Complete an incident report detailing the client scenario: Completing an incident report may be necessary later, but the priority should be to address the client’s safety and ensure they are making an informed decision about leaving the facility. The nurse should first engage with the client regarding their choice and the associated risks.
Correct Answer is C
Explanation
A. Lower maternal morbidity rates: Rural health often does not reflect lower maternal morbidity rates. In fact, rural areas may experience higher maternal morbidity due to limited access to healthcare services, fewer prenatal resources, and a shortage of specialized medical providers, leading to potential complications during pregnancy.
B. Reduced incidence of death from motor-vehicle crashes: Rural areas tend to have higher rates of motor vehicle crashes due to factors such as longer travel distances, less regulated driving conditions, and often poorly maintained roads. These conditions contribute to an increased risk of accidents and fatalities in these regions.
C. Increased rates of chronic illness: Rural health is often characterized by increased rates of chronic illnesses, such as hypertension, diabetes, and obesity. Contributing factors include limited access to healthcare, fewer health education resources, socioeconomic disparities, and lifestyle factors like diet and exercise habits that may be less favorable in rural settings.
D. More frequent dental preventative care visits: Rural areas typically have fewer dental care resources and access, which can lead to less frequent dental visits for preventative care. This situation can result in higher rates of dental issues and a lack of regular screenings and treatments for oral health problems.
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