An emergency department nurse is providing handoff communication using SBAR (situation, background, assessment, recommendations) to the nurse accepting a client in the intensive care unit. The emergency department nurse reports that the client will require a suction set up for gastric tube drainage and will need an endoscopy performed. Which of the following parts of the SBAR report is the nurse communicating?
S-Situation
R-Recommendations
B-Background
A-Assessment
The Correct Answer is B
A. S–Situation: The situation includes immediate information about why the client is being transferred or receiving care, such as current symptoms, diagnosis, or presenting complaint. It does not include upcoming procedures or equipment needs.
B. R–Recommendations: Recommendations include what actions or interventions are needed next, such as upcoming tests, procedures, or equipment setup. Mentioning the need for a suction setup and an endoscopy reflects planning for ongoing care and falls under this category.
C. B–Background: Background refers to the client's medical history, diagnosis, and events leading up to the current situation. It gives context but does not include plans for future care.
D. A–Assessment: Assessment includes clinical findings, vital signs, laboratory results, and how the client is currently presenting. It focuses on objective and subjective data, not future recommendations or equipment planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Response to noxious stimuli: While assessing the response to noxious stimuli can be an important part of neurological assessment, it is not specific to mild traumatic brain injury (TBI). The primary focus should be on cranial nerve assessment to evaluate brain function and detect any early signs of deterioration.
B. Obstructive sleep apnea: Obstructive sleep apnea is not a typical concern for a client with mild TBI. The focus should be on the immediate effects of the injury, such as cranial nerve function, rather than conditions unrelated to the head injury.
C. Trousseau's sign: Trousseau's sign is a test used to assess for latent tetany (muscle spasms), typically in cases of hypocalcemia. It is not relevant for a client with mild TBI unless there are other symptoms indicating electrolyte imbalances, which are not the primary concern in this case.
D. Cranial nerve assessment: Cranial nerve assessment is a key part of evaluating the neurological status of a client with mild TBI. It helps identify any deficits or changes in brain function that may indicate deterioration or more severe injury. This should be part of the plan of care for a mild TBI client.
Correct Answer is A
Explanation
A. Crohn's disease has the appearance of a patchwork quilt with some areas that are clear and some with sores: This description simplifies the concept of Crohn's disease by using the analogy of a patchwork quilt, which helps convey the characteristic "skip lesions" seen in the condition. In Crohn's disease, areas of inflammation (sores) are interspersed with healthy tissue, making this analogy easily understandable for a client without medical knowledge.
B. Crohn's disease looks like what would appear to be a second-degree burn in the colon and rectum areas only: This description falsely limits Crohn's disease to only the colon and rectum. Crohn's disease can affect any part of the gastrointestinal tract, from the mouth to the anus, and not just the colon or rectum. Additionally, comparing it to a burn may confuse the client, as it does not accurately depict the disease's pathophysiology.
C. Crohn's disease is characterized by a transmural granulomatous inflammation that can affect any part of the gastrointestinal tract: While this statement is medically accurate, it is complex and uses terminology (transmural, granulomatous) that may be difficult for a layperson to understand. For client education, it is better to use simpler language that avoids jargon and focuses on the general concept of the disease.
D. Crohn's disease causes continuous inflammation of the mucosa and sub-mucosa of the colon and rectal linings: This statement describes ulcerative colitis, not Crohn's disease. While Crohn's disease involves inflammation, it is characterized by patchy, non-continuous lesions (skip lesions), which differ from the continuous inflammation seen in ulcerative colitis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
