A patient who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation.
When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, what information should the nurse provide first?
Client’s healthcare power of attorney.
Currently prescribed medications.
Fall at home as reason for admission.
Increasing confusion of the patient.
The Correct Answer is D
Choice A rationale
While the client’s healthcare power of attorney is important information, it is not the most critical piece of information to report in this situation. The immediate concern is the client’s change in mental status and potential medical emergency.
Choice B rationale
The nurse should be aware of the client’s currently prescribed medications, but this information does not take precedence over the client’s sudden onset of confusion and agitation. Immediate action is needed to address the client’s altered mental status.
Choice C rationale
While the reason for the client’s admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client’s acute change in mental status.
Choice D rationale
Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client’s immediate needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Listening for bilateral breath sounds is a common method to confirm the correct placement of the ETT1. When the ETT is correctly placed, breath sounds should be heard equally on both sides of the chest.
Choice B rationale
Verifying a capillary refill time of less than 3 seconds is not directly related to confirming the placement of an ETT. Capillary refill time is often used to assess peripheral circulation and hydration status, not airway management.
Choice C rationale
Checking that the ETT markings are between 22 and 26 cm at the teeth line is another method to confirm correct ETT placement. These markings help ensure that the ETT is not too far into the trachea, which could cause one lung to be ventilated more than the other.
Choice D rationale
Observing for symmetrical chest movement is a visual confirmation of correct ETT placement. When the ETT is correctly placed, both sides of the chest should rise and fall equally with each breath.
Choice E rationale
Arranging for a portable chest x-ray is considered the gold standard for confirming ETT location. It provides a visual confirmation that the ETT is in the trachea and not in the esophagus.
Correct Answer is []
Explanation
Based on the information provided, the client is most likely experiencinganorexia nervosa.This is suggested by her significant weight loss, bradycardia, hypothermia, lanugo-type hair, and her expressed fear of gaining weight despite being underweight. However, this is a preliminary assessment and a definitive diagnosis should be made by a healthcare professional.
Actions the nurse should take to address this condition include:
- Acknowledge anxious feelings: It’s important to validate the client’s feelings and fears about food and weight gain.This can help build trust and facilitate further discussion about her health.
- Provide emotional support: Emotional support is crucial in managing eating disorders.The nurse can provide reassurance, listen empathetically, and encourage the client to express her feelings.
Parameters the nurse should monitor to assess the client’s progress include:
- Nutritional intake: Monitoring the client’s food and fluid intake can help assess her nutritional status and response to treatment.
- Weight and BMI: Regular monitoring of the client’s weight and BMI can provide objective measures of her nutritional status and response to treatment.
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