A nurse is providing change-of-shift report to another nurse for a client using the Introduction, Situation, Background, Assessment and Recommendation (ISBARR) communication tool. Which of the following information should the nurse include as part of the situation component of this communication tool?

Medical condition

Treatment

Vital signs

List of medications

Answer and Explanation

The Correct Answer is A

Explanation:

A. Medical condition:

Including the client's medical condition in the Situation component of the ISBARR communication tool is important because it provides an overview of the client's health status. This may include a brief description of the primary diagnosis, current symptoms, or any significant changes in the client's condition since the last shift. It helps the receiving nurse understand the context and urgency of the report.

B. Treatment:

While treatment information is crucial for providing comprehensive care to the client, it is typically included in the Background or Assessment components of the ISBARR communication tool. The Situation component focuses on summarizing the client's current status rather than detailing specific treatments or interventions.

C. Vital signs:

Vital signs, such as heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation, are essential clinical data. However, they are usually included in the Assessment component of the ISBARR communication tool, where the nurse provides a detailed assessment of the client's physiological parameters and trends.

D. List of medications:

Similar to treatment information, a list of medications is typically included in the Background or Assessment components of the ISBARR communication tool. It is important for the receiving nurse to know what medications the client is taking, including doses, frequencies, and any recent changes, but this information is more detailed and specific than what is typically included in the Situation component.

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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.

A. "Reporting is voluntary for health care workers." B. "Civil liability can result if the abuse can't be proven." C. "Evidence of abuse must be collected prior to reporting." D. "If suspicion of abuse exists then reporting is mandatory."

Correct Answer is D

Explanation

Explanation:

A. "Reporting is voluntary for health care workers."

This statement is incorrect. Reporting child abuse is not voluntary for healthcare workers; it is a legal requirement in many jurisdictions. Failure to report suspected abuse can lead to legal and professional consequences.

B. "Civil liability can result if the abuse can't be proven."

While civil liability may be a concern in some situations, it is not the primary reason for reporting child abuse. The main purpose of reporting is to ensure the safety and well-being of the child, not to prove abuse in a legal sense.

C. "Evidence of abuse must be collected prior to reporting."

This statement is incorrect. While collecting evidence can be important in legal proceedings, it is not the responsibility of healthcare workers to collect evidence of abuse before reporting. Suspected cases of abuse should be reported promptly to the appropriate authorities, who are responsible for investigating and gathering evidence.

D. "If suspicion of abuse exists then reporting is mandatory."

This statement correctly reflects the legal and ethical obligation of healthcare workers to report suspected cases of child abuse. Healthcare professionals are mandated reporters, which means they are required by law to report any suspicion of child abuse or neglect, even if there is no concrete evidence. Reporting is not voluntary for healthcare workers, and failure to report suspected abuse can result in serious consequences, including legal penalties and professional sanctions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at the end of life. Which of the following interventions is most effective in reducing the client's social isolation?

Correct Answer is C

Explanation

A nurse is discussing the reporting of child abuse with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is discussing the process of evidence-based practice (EBP). Which of the following sources should the nurse identify as being examples of credible sources of information? (Select All that Apply.)

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?

A nurse is reinforcing teaching with a newly licensed nurse regarding sources of medication information. Which of the following resources should the nurse include as reliable references for the nurse to use to evaluate medication information? (Select all that apply.)(Select All that Apply.)

A nurse is collecting data from a client who is at the end of life. Which of the following findings should the nurse expect?

A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?

A nurse is collecting data from a client who is at the end of life. Which of the following findings should the nurse expect?

A nurse is assisting with teaching a class about the effects of spirituality for clients who are near the end of life. Which of the following information should the nurse include?