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?

Glasgow coma scale result

History of the injury

Medication during the next shift

Intracranial pressure readings

Answer and Explanation

The Correct Answer is B

Explanation:

A. Glasgow coma scale result - This would be included in the assessment segment of SBAR, as it provides a clinical evaluation of the client's current neurological status.

B. History of the injury - The situation segment is used to briefly explain the current situation or the reason for the report. Including the history of the injury provides context about why the client is receiving care.

C. Medication during the next shift - This information is part of the Recommendation segment of SBAR. The nurse should include any upcoming medication administration, changes in medication orders, or specific medications that need to be administered during the next shift.

D. Intracranial pressure readings - This information should be included in the Assessment segment of SBAR. It provides important data about the client's intracranial status, helps monitor for changes or trends, and guides ongoing management and interventions.

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Correct Answer is C

Explanation

Explanation:

A. Moist mucous membranes - This is unlikely in an end-of-life scenario. As death approaches, mucous membranes often become dry due to decreased fluid intake and decreased body function.

B. Tachycardia - Tachycardia, or a rapid heart rate, can be a common finding as death nears. It can result from various factors such as dehydration, fever, pain, or the body's response to stress.

C. Irregular respirations - Irregular respirations, including periods of apnea or agonal breathing (gasping, irregular, or shallow breaths), are typical findings in the end-of-life stage. These irregularities are part of the body's natural process as it shuts down.

D. Hypertension - Hypertension is less common in the end-of-life phase. Typically, blood pressure decreases as the body's systems begin to fail.

A. Encourage family members to call the client. B. Instruct the client to join an online support group. C. Schedule home visits with the client. D. Ask the client's friends to text the client.

Correct Answer is C

Explanation

Explanation:

A. Encourage family members to call the client: This option focuses on utilizing the client's existing support system, particularly family members, to maintain communication and emotional connection. Regular phone calls from family members can provide comfort, reassurance, and a sense of belonging, all of which are crucial in reducing social isolation, especially during end-of-life care.

B. Instruct the client to join an online support group: This option suggests using technology to connect the client with others who may be going through similar experiences. Online support groups can offer valuable emotional support and a sense of community. However, this approach may not be suitable for all clients, especially if they are not comfortable or familiar with online platforms, or if they prefer face-to-face interactions.

C. Schedule home visits with the client: This option emphasizes personal, one-on-one interaction by scheduling regular home visits. Home visits allow healthcare providers, family members, and other supportive individuals to be physically present with the client, providing not only emotional support but also addressing any physical or comfort needs the client may have.

D. Ask the client's friends to text the client: Texting is a convenient and quick way to communicate, but it may lack the depth of connection provided by voice calls or in-person interactions. While texting can be an additional method of staying in touch, especially for quick updates or reminders, it may not be sufficient on its own to reduce social isolation significantly.

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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?

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