A nurse is contacting the provider about a client. Which statement is an example of the S in SBAR?
"The client may be having a cardiac event".
"The client needs an EKG. Please see her immediately".
"The client is experiencing chest pain and shortness of breath".
"The client's admitting diagnosis is stage 2 breast cancer".
The Correct Answer is C
A) "The client may be having a cardiac event": While this statement indicates a potential concern, it lacks specific details about the client's current condition. It suggests a possibility but does not clearly communicate the immediate issue or symptoms being experienced.
B) "The client needs an EKG. Please see her immediately": This statement expresses urgency and a request for action but does not provide the necessary context or information about the client's symptoms. It is more aligned with the "Request" part of SBAR rather than the "Situation."
C) "The client is experiencing chest pain and shortness of breath": This statement accurately describes the current situation the client is facing. It provides essential information regarding the symptoms the nurse is observing, making it a clear example of the "Situation" in the SBAR framework. This information is critical for the provider to understand the urgency of the situation.
D) "The client's admitting diagnosis is stage 2 breast cancer": While this statement provides important background information, it does not reflect the immediate situation that requires attention. It does not address the current health issue that is prompting the nurse to contact the provider.
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Correct Answer is ["A","C","D"]
Explanation
A) Texture: Assessing the texture of the skin is an important part of a comprehensive skin assessment. It provides insights into the health and hydration status of the skin. Normal skin texture should feel smooth and even, while changes can indicate issues such as dryness or conditions like eczema or psoriasis.
B) Tachypnea: This term refers to an increased respiratory rate and is not a characteristic assessed in the skin. While it can indicate a physiological response to various conditions, it does not relate to skin health or characteristics and therefore is not relevant in this context.
C) Turgor: Skin turgor refers to the elasticity and hydration status of the skin, which can be assessed by pinching the skin. Proper turgor indicates adequate hydration, while decreased turgor can signal dehydration or other health issues. This is an essential component of skin assessment.
D) Temperature: Assessing the temperature of the skin can provide information about circulation and potential inflammation or infection. Normal skin temperature should feel warm and consistent, while variations can suggest underlying conditions such as fever or shock.
E) Tympany: Tympany is a term used in percussion assessments of the abdomen and is not applicable to skin assessment. It refers to a hollow sound produced by tapping on a body surface and does not pertain to skin characteristics.
Correct Answer is A
Explanation
A) "What can we do to accommodate your needs during your stay here?" This response is the most appropriate as it demonstrates cultural sensitivity and respect for the client’s religious practices. It opens the door for a collaborative discussion about how the healthcare team can support the client’s fasting while ensuring that his health needs are met during hospitalization.
B) "I will let your healthcare provider know that you need to be discharged." While it is important to communicate the client’s needs to the healthcare provider, suggesting discharge may not be a feasible solution. It does not address the complexities of fasting during hospitalization and could imply that the client’s faith is a burden rather than a respected aspect of their care.
C) "Fasting may be harmful to your body during your illness." While it is crucial to ensure the client’s health is not compromised, this response could come off as dismissive of the client’s beliefs. Instead of expressing concern, it could be more beneficial to explore how fasting can be managed within the context of their medical care.
D) "You must eat a high protein diet during times of illness." This response does not take into account the client’s religious beliefs and fails to respect the significance of fasting in the Muslim faith. While dietary considerations are important, this approach disregards the client’s right to practice their faith and may come across as prescriptive rather than collaborative.