A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation? (Select all that apply.)
Primary health problem
Admission vital signs from 1 week ago
Scheduled times for dressing changes
Number of family members who have visited
Current medication prescriptions
Correct Answer : A,C,E
A. Primary health problem: This is correct as it provides critical context for the client's current condition and the reason for the transfer.
B. Admission vital signs from 1 week ago: This is incorrect because recent vital signs are more relevant to the current status of the client; historical data from a week ago is less pertinent.
C. Scheduled times for dressing changes: This is correct as it is important for the receiving unit to know about ongoing care needs related to wound management.
D. Number of family members who have visited: This is incorrect as it does not pertain to the client's medical condition or immediate care needs.
E. Current medication prescriptions: This is correct as it is essential for the new care team to have information on the medications the client is currently taking to ensure continuity of care.
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Related Questions
Correct Answer is A
Explanation
A. Participate in reminiscence therapy with the client: This is correct as reminiscence therapy, which involves discussing past experiences and memories, can help improve mood and cognitive function in clients with Alzheimer's disease.
B. Alternate the client's daily routine: Consistency is important for clients with Alzheimer's disease to reduce confusion and anxiety. Alternating the routine can be disorienting.
C. Keep the lights dimmed: Keeping the lights dimmed can contribute to confusion and disorientation. Adequate lighting is essential for safety and to help the client maintain a clear sense of time and space.
D. Raise the four side rails on the client's bed: Raising all four side rails can be considered a form of restraint and is not recommended. It can increase the risk of injury and does not address the client's needs appropriately.
Correct Answer is C
Explanation
A. "I will increase vitamin C intake by drinking orange juice": This is incorrect because citrus juices like orange juice can exacerbate GERD symptoms by increasing acid production.
B. "I will lie down for 30 minutes after each meal": This is incorrect as lying down after eating can increase the risk of acid reflux. Clients should remain upright for at least 2-3 hours after eating.
C. "I will eat six small meals each day": This is correct because eating smaller, more frequent meals can help reduce the frequency of GERD symptoms by decreasing stomach pressure and acid production.
D. "I will sleep flat on my back at night": This is incorrect as sleeping flat can worsen GERD symptoms. Elevating the head of the bed can help prevent acid reflux during sleep.
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