An older client admitted for observation following a fall while getting out of the bathtub becomes increasingly confused. The family arrives with the home medication list and the client’s healthcare power of attorney. When providing a report to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which 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 client.

Answer and Explanation

The Correct Answer is D

Choice A: Client’s healthcare power of attorney. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The healthcare power of attorney is a legal document that designates who can make medical decisions for the client if they are unable to do so themselves.

Choice B: Currently prescribed medications. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The currently prescribed medications are a part of the background information that can help explain the client’s medical history and potential causes of confusion.

Choice C: Fall at home as reason for admission. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The fall at home is a part of the background information that can help explain the client’s reason for admission and potential injuries.

Choice D: Increasing confusion of the client. This is the first information that the nurse should provide, as it addresses the current situation or problem of the client. The increasing confusion of the client is a part of the assessment information that can help identify the urgency and severity of the issue and guide further interventions.

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Correct Answer is C

Explanation

Choice A: When the client has ankle edema is not the most important time for the nurse to assess DTRs, as this is a common finding in pregnancy and does not indicate a neurological or vascular problem. This is a distractor choice.

Choice B: Within the first trimester of pregnancy is not the most important time for the nurse to assess DTRs, as this is a routine assessment that can be done at any time during pregnancy and does not reflect any specific risk or complication. This is another distractor choice.

Choice C: If the client has an elevated blood pressure is the most important time for the nurse to assess DTRs, as this can indicate preeclampsia, a serious condition that can cause seizures, stroke, and organ damage. DTRs can help detect hyperreflexia, which is a sign of increased intracranial pressure and impending eclampsia. Therefore, this is the correct choice.

Choice D: During admission to labor and delivery is not the most important time for the nurse to assess DTRs, as this is a standard assessment that can be done at any stage of labor and does not signify any urgent or emergent situation. This is another distractor choice.

A. Maintain a quiet, non-stimulating environment. B. Force oral fluids and provide frequent small meals. C. Confront the client's denial of substance abuse. D. Encourage attendance and group participation.

Correct Answer is A

Explanation

Choice A is correct because a quiet, non-stimulating environment can help reduce the agitation, confusion, and hallucinations that are common in alcohol withdrawal delirium. The nurse should also provide reassurance, orientation, and safety measures to the client.

Choice B is incorrect because forcing oral fluids and providing frequent small meals are not the most important interventions for a client with alcohol withdrawal delirium. The client may have difficulty swallowing, nausea, vomiting, or diarrhea that can interfere with oral intake. The nurse should monitor the client's hydration and nutrition status and provide intravenous fluids or supplements as needed.

Choice C is incorrect because confronting the client's denial of substance abuse is not the most important intervention for a client with alcohol withdrawal delirium. The client may not be able to comprehend or accept the reality of their situation due to their altered mental state. The nurse should avoid arguing or challenging the client and focus on providing supportive care.

Choice D is incorrect because encouraging attendance and group participation are not the most important interventions for a client with alcohol withdrawal delirium. The client may not be able to participate in group activities due to their severe withdrawal symptoms and may need individualized care. The nurse should facilitate referrals to appropriate resources for substance abuse treatment when the client is stable and ready.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

Correct Answer is C

Explanation

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

Correct Answer is A

Explanation

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?

Days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client had a pulmonary embolus. Which action should the nurse take first?

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg intravenously every 12 hours. The medication is available at 10 mg/mL. How many mL should the nurse administer? (Enter numeric value only)