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 A

Explanation

The correct answer is A. Flushed, peeling skin

Choice A reason: Flushed, peeling skin is a classic sign of scarlet fever, which is a condition that can arise from Streptococcal pharyngitis. Scarlet fever is characterized by a red rash that can cover most of the body and may lead to the skin peeling. This symptom is a direct reaction to the toxins produced by the Streptococcal bacteria.

Choice B reason: Red bumps across the chest could be indicative of many conditions and are not specifically characteristic of the reaction to toxins produced by Streptococcal bacteria. While a rash is common in scarlet fever, it typically starts on the face or neck and spreads to the rest of the body, rather than presenting as isolated red bumps.

Choice C reason: A white coating on the tongue, often referred to as “strawberry tongue,” is indeed associated with scarlet fever. However, it is not the clearest indication of a reaction to the toxins. The white coating usually precedes the strawberry-like appearance, where the tongue becomes red and bumpy.

Choice D reason: While a high fever is a symptom of scarlet fever, it is not specific to the reaction to toxins from Streptococcal bacteria, as many infections can cause high fevers. The term “protracted” suggests a prolonged fever, which could be seen in various conditions.

A. Provide diet low in phosphorus. B. Note signs of swelling and edema. C. Increase oral fluid intake to 1,500 mL daily. D. Monitor abdominal girth. E. Report serum albumin and globulin levels.

Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Providing diet low in phosphorus is not a relevant intervention for a client with cirrhosis of the liver. Phosphorus is a mineral that helps maintain bone health and acid-base balance. Cirrhosis of the liver does not affect phosphorus levels, but it can cause low calcium levels due to impaired vitamin D metabolism. The nurse should provide a diet high in calcium and vitamin D to prevent osteoporosis and fractures.

Choice C reason: Increasing oral fluid intake to 1,500 mL daily is not a suitable intervention for a client with cirrhosis of the liver. Fluid intake should be individualized based on the client's fluid status, electrolyte levels, and urine output. Increasing fluid intake may worsen fluid retention and electrolyte imbalance in clients with cirrhosis of the liver. The nurse should restrict fluid intake to 1,000 to 1,500 mL daily or as prescribed by the healthcare provider.

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Naxlex Comprehensive Predictor Exams

A preschool-aged child who is being tested for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the clearest indication to the nurse that the child is experiencing a reaction to toxins that are created by Streptococcal bacteria.

Correct Answer is A

Explanation

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.)

Correct Answer is ["B","D","E"]

Explanation

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?White Blood Cell (WBC. Reference Range: 5000-10,000/mm^3 (5-10 x 10^9/L)

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

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

A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which intervention should the nurse provide to address the client's problem?

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?