A patient is brought to the emergency department after falling from a ladder and is exhibiting signs of confusion and disorientation.

The spouse reports that the patient seemed to have lost consciousness.

The nurse has been provided with a list of current medications and healthcare power of attorney.

When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

The patient’s currently prescribed medications.

The increasing confusion of the patient.

The patient’s healthcare power of attorney.

The fall from a ladder as the reason for admission.

Answer and Explanation

The Correct Answer is D

Choice A rationale
While it’s important to know the patient’s current medications as they can influence the patient’s condition and treatment plan, this information is not the most critical to convey first in this situation.
Choice B rationale
The increasing confusion of the patient is a significant symptom, especially after a fall. It could indicate a possible head injury. However, the cause of the confusion (the fall) should be communicated first.
Choice C rationale
Knowing who holds the patient’s healthcare power of attorney is important, especially if the patient’s condition worsens and decisions need to be made on their behalf. However, this information is not the most critical to convey first.
Choice D rationale
The fall from a ladder as the reason for admission is the most important information to provide first. This gives the healthcare provider immediate context about the potential severity and type of injuries, guiding further assessment and treatment.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A rationale
Hyperventilation leads to a decrease in the amount of carbon dioxide (CO2) in the blood. This causes the pH of the blood to increase, resulting in respiratory alkalosis.
Choice B rationale
Respiratory acidosis is caused by a buildup of CO2 in the blood, typically due to hypoventilation (under-breathing). This is not consistent with the patient’s symptoms of hyperventilation.
Choice C rationale
Metabolic alkalosis is typically caused by a significant loss of acid from the body, such as from prolonged vomiting. This is not consistent with the patient’s symptoms.

Choice D rationale
Metabolic acidosis is typically caused by an increase in acid production within the body or a loss of bicarbonate from the body, such as in diabetic ketoacidosis or kidney disease. This is not consistent with the patient’s symptoms.

A. Perform a thorough physical assessment B. Develop a safety plan C. Take photographs to document the abuse or neglect D. Confront the abuser about concerning actions E. he client in front of the suspected abuser F. Complete a comprehensive history G. Throw away soiled clothing

Correct Answer is ["A","B","C","F"]

Explanation

Choice A rationale
Performing a thorough physical assessment is crucial when elder mistreatment is suspected. It helps to identify any signs of physical abuse or neglect.
Choice B rationale
Developing a safety plan is an important step in ensuring the safety of the elder. This plan can include strategies to avoid potential harm and steps to take if the elder feels unsafe.
Choice C rationale

Taking photographs to document the abuse or neglect can provide concrete evidence of the mistreatment. These photographs can be used in investigations and legal proceedings.
Choice F rationale
Completing a comprehensive history is necessary to understand the full context of the elder’s situation. This includes the elder’s health status, living conditions, and the nature of their relationship with the caregiver.
Choice H rationale
Reporting findings to Adult Protective Services is a critical step in addressing elder mistreatment. Adult Protective Services can conduct further investigations and take necessary actions to protect the elder.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adolescent arrives at the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain. The patient is anxious, fearful, and hyperventilating. What acid-base imbalance does the nurse anticipate the patient will develop?

Correct Answer is A

Explanation

What intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Correct Answer is ["A","B","C","F"]

Explanation

A client who follows Mormon beliefs is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply.

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

The nurse is preparing a 50 mL dose of 50% dextrose IV for a patient with insulin shock. What is the appropriate method for administering the medication?

A client with a deep vein thrombosis (DVT) in the left leg is on a heparin protocol. What is the most crucial intervention for the nurse to include in this client’s care plan?

A nurse is preparing a 50 mL dose of 50% dextrose IV for a patient experiencing insulin shock. What is the best method for administering the medication?