A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?

Glasgow results

Intracranial pressure readings

Code status

Plan of care changes for upcoming shift

Answer and Explanation

The Correct Answer is B

A. Glasgow results: This information would typically be included in the "Assessment" section of SBAR, as it relates to the current status of the client.

B. Intracranial pressure readings: This information is appropriate for the "Background" segment of SBAR as it provides relevant context about the client's condition that could impact the plan of care.

C. Code status: This information should be included in the "Background" section if it is relevant to the client's overall care and treatment plan, but it is not specific to the immediate context of the traumatic brain injury.

D. Plan of care changes for upcoming shift: This information belongs in the "Recommendation" or "Plan" section of SBAR, as it involves the actions or changes planned for the client’s care during the upcoming shift.

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Correct Answer is A

Explanation

A. I will check your medication order again: This response addresses the client's concern by verifying that the medication is correct and reassures the client by ensuring that the prescribed medication matches their expectation.

B. Sometimes the same pill comes in a different color: While this might be true, this response does not directly address the client’s concern about the specific medication they are supposed to take.

C. Let me explain the purpose of the medication: This response is helpful but does not address the client's concern about the discrepancy in the medication's appearance.

D. This is the medication that your doctor wants you to take: This response may not resolve the client's concern about the pill's color and does not involve verifying the medication’s accuracy.

A. Pull the auricle down and out. B. Pull the auricle up and back. C. Pull the auricle up and out. D. Pull the auricle down and back.

Correct Answer is A

Explanation

A. Pull the auricle down and out: For a child under 3 years old, the ear canal is more horizontal, so the auricle should be pulled down and out to straighten the ear canal for proper instillation of ear drops.

B. Pull the auricle up and back: This technique is used for children older than 3 years old, as their ear canal becomes more vertical.

C. Pull the auricle up and out: This technique is incorrect for a 3-year-old child as it does not account for the horizontal position of the ear canal in younger children.

D. Pull the auricle down and back: This technique is not recommended for ear drops in young children and does not align with the anatomical considerations for their ear canal.

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A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?

Nursing Test Bank

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