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NurseDive Free Nursing Practice Question
A nurse is giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of SBAR?
A. Glasgow coma scale result
Glasgow coma scale result - This would be included in the assessment segment of SBAR, as it provides a clinical evaluation of the client's current neurological status.
B. History of the injury
History of the injury - The situation segment is used to briefly explain the current situation or the reason for the report. Including the history of the injury provides context about why the client is receiving care.
C. Medication during the next shift
Medication during the next shift - This information is part of the Recommendation segment of SBAR. The nurse should include any upcoming medication administration, changes in medication orders, or specific medications that need to be administered during the next shift.
D. Intracranial pressure readings
Intracranial pressure readings - This information should be included in the Assessment segment of SBAR. It provides important data about the client's intracranial status, helps monitor for changes or trends, and guides ongoing management and interventions.
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Full Explanation
Explanation:
A. Glasgow coma scale result - This would be included in the assessment segment of SBAR, as it provides a clinical evaluation of the client's current neurological status.
B. History of the injury - The situation segment is used to briefly explain the current situation or the reason for the report. Including the history of the injury provides context about why the client is receiving care.
C. Medication during the next shift - This information is part of the Recommendation segment of SBAR. The nurse should include any upcoming medication administration, changes in medication orders, or specific medications that need to be administered during the next shift.
D. Intracranial pressure readings - This information should be included in the Assessment segment of SBAR. It provides important data about the client's intracranial status, helps monitor for changes or trends, and guides ongoing management and interventions.
Similar Questions
A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and, based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first?
A. Arrange referral for family therapy to deal with home stressors.
Arrange referral for family therapy to deal with home stressors:While family therapy may be beneficial for addressing home stressors, it is not the first step when there is a suspicion of physical abuse. The priority in cases of suspected abuse is to ensure the client's safety and to report the suspicion to the appropriate authorities.
B. Follow the agency's guidelines for reporting suspected abuse.
Follow the agency's guidelines for reporting suspected abuse:This is the correct action to take first. Nurses are mandated reporters, and they must follow their agency's protocols and legal requirements for reporting suspected abuse. Reporting ensures that the client's situation is investigated promptly, and appropriate interventions are implemented to protect the client.
C. Check the bruises at the next visit to the client's home.
Check the bruises at the next visit to the client's home:Delaying action and waiting until the next visit to check the bruises is not appropriate in cases of suspected abuse. Immediate action is necessary to address the safety of the client. Suspected abuse should be reported promptly to the relevant authorities for investigation.
D. Institute more frequent visits to the client's home.
Institute more frequent visits to the client's home:Increasing the frequency of visits may not address the immediate safety concerns of the client if abuse is suspected. While increased monitoring may be necessary in certain situations, reporting the suspicion of abuse and initiating appropriate interventions should take precedence.
Full Explanation
Explanation:
A. Arrange referral for family therapy to deal with home stressors:
While family therapy may be beneficial for addressing home stressors, it is not the first step when there is a suspicion of physical abuse. The priority in cases of suspected abuse is to ensure the client's safety and to report the suspicion to the appropriate authorities.
B. Follow the agency's guidelines for reporting suspected abuse:
This is the correct action to take first. Nurses are mandated reporters, and they must follow their agency's protocols and legal requirements for reporting suspected abuse. Reporting ensures that the client's situation is investigated promptly, and appropriate interventions are implemented to protect the client.
C. Check the bruises at the next visit to the client's home:
Delaying action and waiting until the next visit to check the bruises is not appropriate in cases of suspected abuse. Immediate action is necessary to address the safety of the client. Suspected abuse should be reported promptly to the relevant authorities for investigation.
D. Institute more frequent visits to the client's home:
Increasing the frequency of visits may not address the immediate safety concerns of the client if abuse is suspected. While increased monitoring may be necessary in certain situations, reporting the suspicion of abuse and initiating appropriate interventions should take precedence.
A nurse on a medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse that one of the children is a potential victim of abuse?
A. A preschooler who has a BMI indicating obesity
While childhood obesity is a health concern, it is not a specific indicator of abuse. Obesity can result from dietary habits, lack of physical activity, or medical conditions.
B. A school-age child who cries when the nurse is giving him an injection
Fear of injections is common in children and is a typical developmental response. Crying during an injection is not an indicator of abuse and is expected behavior for many children.
C. An adolescent who asks to stay in the hospital because he likes the room
While this finding alone does not confirm abuse, it may indicate an underlying issue in the adolescent's home environment. It requires further exploration through careful, open-ended questioning to assess for potential emotional or physical abuse or neglect.
D. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy
Bruising on the shins of toddlers is common due to normal play and falls during development. The explanation provided by the parents aligns with typical toddler behavior and does not raise immediate concerns for abuse unless the bruises are in unusual locations (e.g., abdomen, back, or thighs).
Full Explanation
A. While childhood obesity is a health concern, it is not a specific indicator of abuse. Obesity can result from dietary habits, lack of physical activity, or medical conditions.
B. Fear of injections is common in children and is a typical developmental response. Crying during an injection is not an indicator of abuse and is expected behavior for many children.
C. While this finding alone does not confirm abuse, it may indicate an underlying issue in the adolescent's home environment. It requires further exploration through careful, open-ended questioning to assess for potential emotional or physical abuse or neglect.
D. Bruising on the shins of toddlers is common due to normal play and falls during development. The explanation provided by the parents aligns with typical toddler behavior and does not raise immediate concerns for abuse unless the bruises are in unusual locations (e.g., abdomen, back, or thighs).
A nurse is caring for a client and using active listening skills. Which of the following actions should the nurse take?
A. Have a pen and paper.
Have a pen and paper.Having a pen and paper can be helpful during the conversation as it allows the nurse to jot down important points, keywords, or reminders. However, it's not directly related to active listening itself but can aid in retaining and recalling information.
B. Use intermittent eye contact.
Use intermittent eye contact.Intermittent eye contact is a crucial aspect of active listening. It shows that the nurse is engaged and attentive to the client's communication. However, it's essential to maintain a balance and avoid prolonged staring, which can be perceived as intimidating or intrusive.
C. Sit side-by-side with the client.
Sit side-by-side with the client.Sitting side-by-side with the client can create a sense of partnership and equality in the conversation. It can also help in establishing a comfortable and open environment for communication, which is beneficial for active listening.
D. Lean back in the chair.
Lean back in the chair.Leaning back in the chair can convey a relaxed and open posture, which can contribute to a positive communication atmosphere. However, it's crucial to maintain an attentive posture and avoid appearing disinterested or unengaged.
Full Explanation
Explanation:
A. Have a pen and paper.
Having a pen and paper can be helpful during the conversation as it allows the nurse to jot down important points, keywords, or reminders. However, it's not directly related to active listening itself but can aid in retaining and recalling information.
B. Use intermittent eye contact.
Intermittent eye contact is a crucial aspect of active listening. It shows that the nurse is engaged and attentive to the client's communication. However, it's essential to maintain a balance and avoid prolonged staring, which can be perceived as intimidating or intrusive.
C. Sit side-by-side with the client.
Sitting side-by-side with the client can create a sense of partnership and equality in the conversation. It can also help in establishing a comfortable and open environment for communication, which is beneficial for active listening.
D. Lean back in the chair.
Leaning back in the chair can convey a relaxed and open posture, which can contribute to a positive communication atmosphere. However, it's crucial to maintain an attentive posture and avoid appearing disinterested or unengaged.