A nurse is preparing to obtain a health history from a newly admitted client. Which of the following information should the nurse expect to include?
Laboratory results
Physical examination findings
Health habits
Observed client behaviors
The Correct Answer is C
A. Laboratory results Lab results are diagnostic data, not part of the health history. They are obtained separately through testing.
B. Physical examination findings The physical exam is a separate component of the assessment and is not included in the health history, which focuses on subjective data.
C. Health habits The health history includes subjective data provided by the client, such as dietary habits, exercise routine, smoking, alcohol use, sleep patterns, and medication use. This information helps the nurse understand the client’s lifestyle and risk factors.
D. Observed client behaviors While a nurse may take note of behaviors, the health history is based on the client’s self-reported information, not observations.
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Related Questions
Correct Answer is D
Explanation
A. "You should wear a sterile gown when outside of your room." While protective clothing may be required in certain cases, wearing a sterile gown outside the room is not a standard recommendation for immunocompromised clients.
B. "You'll share a room with a client who is also immunocompromised." Clients who require a protective environment should be placed in a private room to minimize the risk of exposure to infections.
C. "You are required to wear an N95 respirator mask." N95 respirators are typically required for healthcare workers caring for clients with airborne precautions, not for immunocompromised clients in a protective environment.
D. "You will be placed in a positive-pressure airflow room." A positive-pressure room helps keep airborne pathogens out by ensuring that air flows out of the room rather than into it, reducing the risk of infections.
Correct Answer is ["A","B","C"]
Explanation
Client is difficult to arouse – This is concerning and may indicate opioid overdose or sedation due to the recent administration of morphine. The nurse should assess the client's level of consciousness closely and consider reversal of the opioid (naloxone) if the client's level of sedation is excessive.
Respiratory rate 10/min – This is below the normal respiratory rate (12–20 breaths/min) and could indicate respiratory depression, a common side effect of opioids like morphine. Close monitoring and possible intervention are required.
Pulse oximetry 88% on room air (95% to 100%) – The oxygen saturation is low, which could indicate hypoxemia. The nurse should administer supplemental oxygen and notify the provider.
Other Findings:
Pupils are 3 mm, equal, and reactive to light – This is a normal finding and not concerning for opioid overdose.
Blood pressure 99/46 mm Hg – This is slightly lower than normal but not critically low, considering the client's condition. Morphine can cause hypotension, especially in older adults or hypovolemic clients.
Heart rate 61/min – This is within a normal range for some postoperative patients, especially in a restful state.
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