A nurse is assisting with a presentation on health promotion activities for clients who have hypertension. Which of the following should the nurse utilize as a resource for this information?

A critical pathway for clients who have had a stroke

Standards of care for monitoring clients who have a history of blood pressure elevation

Acute care facility protocols for clients experiencing an abrupt change in mental status

Clinical practice guidelines for the management of high blood pressure

Answer and Explanation

The Correct Answer is D

A. A critical pathway for clients who have had a stroke:
Critical pathways are structured multidisciplinary care plans that outline essential steps in the care of patients with specific conditions. While critical pathways are valuable tools for standardized care, they are not specifically focused on health promotion activities for clients with hypertension.

B. Standards of care for monitoring clients who have a history of blood pressure elevation:
Standards of care typically outline the minimum level of care that should be provided to clients based on evidence-based practice. While monitoring clients with a history of blood pressure elevation is important, it does not encompass the comprehensive health promotion activities related to hypertension.

C. Acute care facility protocols for clients experiencing an abrupt change in mental status:
Acute care facility protocols are designed to guide the management of acute changes in a patient's condition. While relevant to patient care, these protocols do not specifically address health promotion activities for clients with hypertension.

D. Clinical practice guidelines for the management of high blood pressure:
Clinical practice guidelines provide evidence-based recommendations for the management of specific health conditions. They typically include information on health promotion activities, risk factor modification, lifestyle interventions, and pharmacological management for clients with hypertension. Therefore, clinical practice guidelines are the most appropriate resource for information on health promotion activities for clients with hypertension.

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Correct Answer is D

Explanation

(A) Glasgow coma scale result:
The Glasgow Coma Scale (GCS) result is important and would be included in the "Assessment" segment of SBAR, as it provides current data on the client's level of consciousness and neurological status.

(B) Intracranial pressure readings:
Intracranial pressure (ICP) readings are crucial for monitoring the client's condition but would be more appropriately included in the "Assessment" or "Background" segments, as they provide ongoing data relevant to the client's current health status and trends.

(C) Medication during the next shift:
Medication information, especially about what needs to be administered during the next shift, would fall under the "Recommendation" segment. This is where the outgoing nurse would specify what needs to be done next for the client's care.

(D) History of the injury:
The history of the injury is part of the "Situation" segment in SBAR reporting. This includes a brief description of why the client is being reported on, providing context for their current condition. For a client with a traumatic brain injury, this would involve a summary of how the injury occurred, which sets the stage for understanding the client's current status and care needs.

A. Diarrhea B. Hyperventilation C. Dry skin D. Abdominal pain

Correct Answer is B

Explanation

(A) Diarrhea: Diarrhea is typically associated with gastrointestinal disorders. It involves frequent loose or watery stools, which is not a symptom of respiratory alkalosis. Respiratory alkalosis is a condition that affects the respiratory system, causing an increase in the rate or depth of respiration, leading to a decrease in the concentration of carbon dioxide in the blood.

(B) Hyperventilation: Hyperventilation is indeed a common finding in respiratory alkalosis. When a person hyperventilates, they breathe out more carbon dioxide than their body produces. This lowers the level of carbon dioxide in the blood, leading to a rise in blood pH and causing the blood to become more alkaline - a state known as alkalosis.

(C) Dry skin: Dry skin is not typically associated with respiratory alkalosis. It’s more common in conditions like dehydration or skin disorders. Respiratory alkalosis is a condition that affects the respiratory system and the balance of acids and bases in the blood, not the skin.

(D) Abdominal pain: Abdominal pain is not typically associated with respiratory alkalosis. It’s more common in gastrointestinal disorders. Respiratory alkalosis is a condition that affects the respiratory system and the balance of acids and bases in the blood, not the digestive system.

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A nurse is assisting with a presentation on health promotion activities for clients who have hypertension. Which of the following should the nurse utilize as a resource for this information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of SBAR?

Correct Answer is D

Explanation

A nurse is assessing a client who has respiratory alkalosis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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