A nurse is assisting with the discharge of a client from an acute care unit to a long-term care facility. Which of the following should the nurse include in the transfer report?

Medication administration record

Name of facility social worker

Need for special equipment

Health insurance information

Answer and Explanation

The Correct Answer is C

A) Medication administration record:

While the medication administration record (MAR) is an essential component of the client's medical records and care plan, it may not be directly relevant to the transfer report between healthcare facilities. The MAR typically remains with the client's medical records and is not routinely included in transfer reports. However, information about the client's current medications and any changes in medication regimen may be communicated as part of the transfer report.

B) Name of facility social worker:

While the name of the facility's social worker may be important for ongoing coordination of care and support services, it is not typically included in the transfer report between healthcare facilities. Communication between social workers may occur separately as part of the transition planning process, but it is not a standard component of the transfer report.

C) Need for special equipment:

When transferring a client from one healthcare setting to another, such as from an acute care unit to a long-term care facility, it is crucial to communicate any specific needs or requirements the client may have, including the need for special equipment. This information ensures that the receiving facility is adequately prepared to meet the client's needs upon arrival and can arrange for the necessary equipment or resources to be available. Examples of special equipment may include mobility aids (wheelchair, walker), assistive devices (hearing aids, oxygen concentrators), or specialized medical equipment (wound care supplies, catheters).

D) Health insurance information:

Health insurance information, including details about the client's coverage, billing, and insurance provider, is essential for financial and administrative purposes but may not be directly relevant to the transfer report between healthcare facilities. However, if specific insurance requirements or authorizations are necessary for the client's care at the receiving facility, this information should be communicated as part of the transfer process.

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Correct Answer is B

Explanation

A) Administer PRN haloperidol IM to the client:

Administering haloperidol is not the first-line intervention for managing behavioral disturbances in clients with dementia, especially in response to acute agitation. While antipsychotic medications like haloperidol may be prescribed in some cases, they should be used judiciously due to the risk of adverse effects, particularly in elderly clients. Additionally, administering medication should not be the first action taken without attempting non-pharmacological interventions.

B) Engage the client in a repetitive activity as a distraction:

This is the most appropriate initial intervention when dealing with an agitated client with dementia. Engaging the client in a repetitive, calming activity can help redirect their focus and reduce agitation. Simple, familiar tasks or activities tailored to the client's preferences can be effective in providing comfort and reducing distress.

C) Apply wrist restraints to the client:

Using physical restraints should be avoided unless absolutely necessary for the safety of the client or others. Restraints can cause physical and psychological harm, increase agitation, and compromise the client's dignity and autonomy. Therefore, restraint use should be a last resort and implemented only after other interventions have been attempted and deemed ineffective or when there is an imminent risk of harm.

D) Place the client in a seclusion room:

Seclusion should not be used as an initial intervention for managing agitation in clients with dementia. Seclusion can exacerbate distress and increase feelings of isolation and fear, which may escalate agitation further. It should only be considered as a last resort for managing severe agitation or aggression when all other interventions have failed and there is a risk of harm to the client or others.

A. Administer liquids to the client using a syringe. B. Elevate the head of the client's bed to 45° during meals. C. Instruct the client to tilt their head back when swallowing. D. Request a speech therapist consult from the provider.

Correct Answer is D

Explanation

A) Administer liquids to the client using a syringe:

Administering liquids using a syringe may not address the underlying issue of food pocketing in the client's cheeks during meals. While syringe feeding may be necessary for clients with severe dysphagia, it does not address the need for comprehensive evaluation and intervention by a speech therapist.

B) Elevate the head of the client's bed to 45° during meals:

Elevating the head of the bed during meals is a standard intervention to help prevent aspiration in clients with dysphagia. While this intervention may be appropriate, it may not directly address the issue of food pocketing in the client's cheeks. Therefore, it is not the most comprehensive intervention for this specific problem.

C) Instruct the client to tilt their head back when swallowing:

Tilting the head back when swallowing is not a recommended intervention for clients with dysphagia. In fact, this maneuver can increase the risk of aspiration, as it can cause food or liquid to enter the airway. Therefore, this intervention would not be appropriate and could potentially exacerbate the client's swallowing difficulties.

D) Request a speech therapist consult from the provider:

This is the most appropriate intervention for addressing the client's dysphagia and food pocketing. Speech therapists are trained to assess and treat swallowing disorders, including pocketing of food in the cheeks. They can conduct a comprehensive evaluation of the client's swallowing function and develop individualized interventions to address the underlying causes of dysphagia. Therefore, requesting a speech therapist consult is the most effective way to manage this issue and improve the client's swallowing safety and efficiency.

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A nurse is assisting with the discharge of a client from an acute care unit to a long-term care facility. Which of the following should the nurse include in the transfer report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

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