A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?

The client's code status

The client's name

A prescribed consultation

The client's vital signs

Answer and Explanation

The Correct Answer is C

A.   The client’s code status (e.g., full code, do not resuscitate) is crucial information for any healthcare provider, especially when transferring care. However, this detail is typically included in the Situation or Assessment sections rather than the Background. It is important to communicate the code status clearly, but it is not part of the historical or contextual information provided in the Background section.
B.   While the client's name is important for identification, it is usually not detailed in the Background section. Instead, it is generally included at the beginning of the report or in the Situation section where initial identification and immediate concerns are presented.
C.   Information about a prescribed consultation (e.g., a referral to a specialist) falls under the Background section of the SBAR. This part of the report should include pertinent historical details and context, such as any previous consultations or significant events that have impacted the client’s current condition.
D.   Vital signs are crucial for assessing the current status of the client but are usually included in the Assessment section of the SBAR. This section provides a summary of the client’s current condition, including vital signs, lab results, and other relevant clinical data.

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Correct Answer is D

Explanation

A. Unilateral ptosis (drooping of one eyelid) is typically related to neuromuscular or neurological issues affecting the eye muscles or nerves, such as those seen in conditions like Horner's syndrome or cranial nerve palsies. While it indicates neurological involvement, it does not specifically pertain to speech or swallowing functions, which are the primary concerns for a speech-language pathologist.
B. An altered level of consciousness (e.g., confusion, drowsiness, or disorientation) can affect overall functional ability and cognitive function but is not directly related to the specific role of speech-language pathology. This finding indicates a need for a broader neurological or medical evaluation rather than a specialized focus on communication or swallowing.
C. While diminished hand-to-mouth coordination can affect feeding and self-care, it is more related to occupational or physical therapy. Speech-language pathologists focus on issues specifically related to communication and swallowing.
D. An impaired voluntary cough is relevant to speech-language pathology because it can be indicative of swallowing difficulties and potential risk for aspiration. Speech-language pathologists assess and treat swallowing disorders (dysphagia) and difficulties with managing oral intake safely.

A. Witness the client's signature on the form B. Teach the client about the risks involved with the procedure. C. Explain the procedure to be performed D. Provide the client with alternative procedure options.

Correct Answer is A

Explanation

A. The nurse's role in the informed consent process typically includes witnessing the client's signature on the consent form. This action confirms that the client has signed the document voluntarily and understands the consent form's content. The nurse does not provide the consent but ensures that the
client’s signature is properly recorded.
B. Teaching the client about the risks involved with the procedure is not typically within the nurse's role. This task is usually the responsibility of the provider or surgeon who performs the procedure. The provider is responsible for explaining the risks, benefits, and alternatives to the client.
C. Explaining the procedure to be performed is also not typically within the nurse’s role. This explanation should be done by the provider or surgeon who will perform the procedure. The provider has the detailed knowledge necessary to describe the procedure, including its steps, risks, and expected outcomes.
D. Providing information about alternative procedure options is part of the informed consent process but is generally done by the provider. The provider is responsible for presenting all possible alternatives to the client, along with their potential risks and benefits.

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A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?

Nursing Test Bank

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