A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?

The time the client received his last dose of pain medication

The client's preferred time for bathing

The steps to follow when providing wound care

The belief that the client has a difficult relationship with his son

Answer and Explanation

The Correct Answer is C

Choice A Reason:
The time the client received his last dose of pain medication is incorrect. While this information is relevant for ongoing pain management, it may not be as critical for the receiving facility unless there are specific pain management protocols in place that need to be followed.
Choice B Reason:
The client's preferred time for bathing is incorrect. While knowing the client's preferences is important for providing individualized care, the preferred time for bathing may not be immediately pertinent to the client's care upon transfer to the rehabilitation facility.
Choice C Reason:
The steps to follow when providing wound care is correct. This information is essential for the receiving facility to ensure proper wound care continues without interruption. It helps ensure consistency in care and minimizes the risk of complications related to wound healing.
Choice D Reason:
The belief that the client has a difficult relationship with his son is incorrect. While psychosocial information about the client is important for holistic care, it may not be the most crucial information to include in the change-of-shift report for transfer to a rehabilitation facility unless it directly impacts the client's medical care or rehabilitation plan.

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Correct Answer is C

Explanation

Choice A Reason:
Medicating the client with alprazolam, should not be the first action as it involves administering medication that could mask underlying issues and may not be appropriate without further assessment.
Choice B Reason:
Reorienting the client to his surroundings, is important for addressing confusion, but it should not be the first action until the nurse has ruled out any immediate physiological concerns.
Choice C Reason:
When a client presents with confusion and agitation after returning from an acute care facility, it's important for the nurse to prioritize assessing the client's physiological status by measuring vital signs. Changes in vital signs could indicate underlying medical issues such as infection, dehydration, or other physiological disturbances that may be contributing to the client's symptoms.
Choice D Reason:
Offering reassurance to the family, is important for providing support, but it should not be the first action as it does not directly address the client's immediate needs related to confusion and agitation.

A. A toddler who cries whenever their parent enters the examination room B. An adolescent who was admitted and refuses to speak to their parents C. A preschooler who was previously toilet trained and now requires diapers in the hospital D. A school-age child who has several abrasions on their lower legs

Correct Answer is D

Explanation

Choice A Reason:
A toddler who cries whenever their parent enters the examination room is incorrect. Toddlers may exhibit separation anxiety or fear of medical procedures, which is a common behavior in this age group.
Choice B Reason:
An adolescent who was admitted and refuses to speak to their parents is incorrect. Adolescents may exhibit behaviors such as withdrawal or reluctance to communicate with parents due to developmental changes, stress, or other factors unrelated to maltreatment.
Choice C Reason:
A preschooler who was previously toilet trained and now requires diapers in the hospital is incorrect. Regression in toileting skills is common in preschoolers during times of stress or illness, such as hospitalization. It does not necessarily indicate maltreatment but may be a response to the unfamiliar environment or medical condition.
Choice D Reason:
A school-age child who has several abrasions on their lower legs is correct. Abrasions on a school-age child's lower legs could potentially indicate physical abuse or neglect, especially if they are unexplained or inconsistent with the child's reported activities. Reporting such findings for further investigation is essential to ensure the safety and well-being of the child.

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A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is assessing a client who has returned from an acute care facility following a brief illness. The nurse observes that the client is confused and agitated. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse working in an emergency department is caring for a group of clients. Which of the following clients should the nurse report for suspected maltreatment?

Correct Answer is D

Explanation

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