A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?
"The client has developed drooping facial features."
"The client may benefit from a neurology consult."
"The client is disoriented and pupils are slow to respond to light."
"The client has a history of hypertension."
The Correct Answer is D
Explanation:
A. "The client has developed drooping facial features."
This statement provides specific information about a recent change in the client's condition, which is relevant background information. It helps the provider understand one of the key reasons for the communication.
B. "The client may benefit from a neurology consult."
While suggesting a neurology consult is a potential recommendation (R) in the SBAR tool, it is not part of the Background (B) component. Background information typically focuses on factual data about the client's history, current condition, and pertinent details relevant to the situation.
C. "The client is disoriented and pupils are slow to respond to light."
Similar to option B, this statement describes the client's assessment findings and current condition rather than providing background information. It would be more appropriate in the Assessment (A) component of the SBAR tool.
D. "The client has a history of hypertension."
This statement provides relevant background information about the client's medical history, specifically their history of hypertension. Including this information in the Background component helps the provider understand the client's baseline health status, which is important for evaluating the current situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Explanation:
A. The number of medication errors avoided after the actions were implemented:
This measure assesses the direct impact of the new actions on reducing medication errors. By tracking the number of errors that were avoided after implementing the interventions, the nurse can gauge the effectiveness of the changes in improving medication safety.
B. A comparison of the number of medication errors before and after the actions were implemented:
This measure involves comparing the baseline number of medication errors before implementing the new actions with the number of errors after implementation. It provides a clear comparison to determine if the interventions have led to a reduction in medication errors over time.
C. Results of a study about the time and money required to implement the changes:
While studying the time and financial resources needed to implement changes is important for evaluating feasibility and resource allocation, it does not directly measure the effectiveness of the actions in reducing medication errors.
D. Results of a staff questionnaire that quantifies staff satisfaction with the changes:
Staff satisfaction is an important aspect of change implementation, but it does not serve as a direct measure of the effectiveness of the actions in reducing medication errors. It reflects staff perceptions rather than objective outcomes related to medication safety.
Correct Answer is D
Explanation
Explanation:
A. Administer the Hamilton depression scale:
The Hamilton Depression Rating Scale is a tool used to assess the severity of depression symptoms in individuals. While assessing the client's depression level is an important aspect of mental health assessment, it is not the immediate priority in this scenario. The client has been admitted following a suicide attempt, indicating an acute risk to their safety. Therefore, the priority at this stage is to ensure the client's safety and prevent any further harm or attempts at self-harm.
B. Make a contract with the client for weight gain:
Making a contract with the client for weight gain, especially in the context of anorexia nervosa, may be an important aspect of the client's overall treatment plan. However, in this scenario, the client's immediate safety takes precedence. The client has a history of depression, substance abuse, and anorexia nervosa, and the primary concern at admission is to prevent any further self-harm or suicide attempts.
C. Review the client's toxicology laboratory report:
Reviewing the client's toxicology laboratory report is important for understanding any recent substance abuse and its potential impact on the client's physical and mental health. However, while this information is relevant to the client's overall care, it is not the first action to take upon admission. The immediate priority is to ensure the client's safety and provide appropriate monitoring and intervention to prevent further harm.
D. Initiate one-to-one nursing observation:
This is the correct answer. Initiating one-to-one nursing observation means assigning a dedicated nurse to continuously monitor and supervise the client closely. This level of observation is crucial in a situation where there is a history of suicide attempt and ongoing risk of self-harm. One-to-one observation allows for immediate intervention if the client shows signs of distress or attempts to harm themselves, ensuring their safety while they are in the acute mental health unit.
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