A nurse is preparing to collect health history data during a client’s admission. Which of the following questions should the nurse use to promote this discussion?

“Do you want to talk about your health concerns?”

“Would it help to discuss your feelings about this hospitalization?”

“Would you tell me about all of your medical issues?”

“What brought you to the hospital?”

Answer and Explanation

The Correct Answer is D

A. "Do you want to talk about your health concerns?"

While this question acknowledges the client's option to discuss health concerns, it is somewhat closed-ended and might not prompt the client to share specific details.

B. "Would it help to discuss your feelings about this hospitalization?"

This question addresses the client's feelings about the hospitalization, which is important for emotional well-being, but it might not directly elicit information about the client's primary health issues.

C. "Would you tell me about all of your medical issues?"

This question is somewhat open-ended but might be overwhelming for the client. It is more effective to start with a focused question about the reason for seeking care.

D. "What brought you to the hospital?"

This open-ended question encourages the client to share their primary reason for seeking healthcare and allows for a comprehensive discussion about the client's health concerns. It gives the client an opportunity to express their own perspective and share the relevant information about their medical condition or symptoms.

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Correct Answer is A

Explanation

A. Check temperature and SPO2

When the nurse finds an adult patient's pulse rate to be 140 beats per minute, it is important to assess other vital signs, particularly temperature and oxygen saturation (SPO2). This helps gather additional information to understand the overall clinical picture and assess for potential underlying causes of the elevated heart rate.

B. Report the rate to the primary care provider:

Reporting the heart rate to the primary care provider may be necessary, but it should not be the immediate action. Assessing other vital signs first provides a more comprehensive understanding.

C. Check the pulse again in 2 hours:

Waiting for 2 hours to recheck the pulse is not appropriate when the heart rate is significantly elevated. Immediate action and further assessment are needed.

D. Record the information:

Recording the elevated heart rate is part of documentation, but it should be accompanied by a more comprehensive assessment of vital signs and potential contributing factors.

A. Assess the client B. Notify the nurse manager C. Complete an incident report D. Call the client’s provider

Correct Answer is A

Explanation

A. Assess the client.

This is the immediate priority. The nurse should assess the patient's current condition to determine the extent of the impact of the error on the patient's health, focusing on respiratory status, vital signs, and signs of fluid overload.

B. Notify the nurse manager.

Once the patient has been assessed and stabilized, the nurse should inform the nurse manager or supervisor about the error. This helps ensure appropriate reporting, investigation, and follow-up actions.

C. Complete an incident report.

After assessing and stabilizing the patient, the nurse should document the error in an incident report. Incident reports are important for organizational learning, identifying patterns, and implementing improvements to prevent future errors.

D. Call the client’s provider.

If the patient's condition is deteriorating or requires immediate attention, the nurse should contact the healthcare provider to discuss the situation, report the error, and collaborate on necessary interventions.

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A nurse is preparing to collect health history data during a client’s admission. Which of the following questions should the nurse use to promote this discussion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While taking an adult patient’s pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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