During a comprehensive health history, a client reports coming into the hospital because he "feels like an elephant is sitting on his chest." The nurse will document this information in which of the following sections?

Family History

Past Medical History

Chief Complaint

Present Illness

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Family History is used to document health events in the patient's family, including diseases that may be hereditary or place the patient at risk. The statement about feeling like an elephant is sitting on the chest is not related to family health but is a description of the patient's current symptoms.

Choice B Reason:
Past Medical History includes information about the patient's past health issues, surgeries, hospitalizations, allergies, and treatments. It does not include current symptoms or the reasons for the current hospital visit.

Choice C Reason:
The Chief Complaint is the section where the nurse documents the primary reason for the patient's visit in their own words. The phrase "feels like an elephant is sitting on his chest" is a classic description of chest pain or discomfort, often associated with cardiac issues, and would be documented here as it represents the patient's main concern.

Choice D Reason:
Present Illness or History of Present Illness would include a detailed account of the development of the patient's illness or health concern. While it is closely related to the Chief Complaint, it is more detailed and includes the onset, duration, and character of the symptoms, among other aspects. The initial statement would be part of the Chief Complaint, which leads into the more detailed History of Present Illness.

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Correct Answer is D

Explanation

Choice a reason:
Bronchovesicular sounds are normal breath sounds heard over the main bronchus area and over the upper right posterior lung field. They have a medium pitch and intensity and are heard on both inspiration and expiration. Bronchovesicular sounds do not involve the change of vowel sounds during auscultation.

Choice b reason:
Bronchophony is the term used when the voice sounds are more clear and louder over the chest wall, usually indicating lung consolidation. However, it does not specifically refer to the change of vowel sounds from "ee" to "ay."

Choice c reason:
Normal voice resonance is when voice sounds heard through auscultation are muffled and indistinct. It does not involve a clear change in vowel sounds, which is what occurs with egophony.

Choice d reason:
Egophony is characterized by the change of the "ee" vowel sound to a nasal "ay" or "a" sound when auscultating the lungs. This phenomenon typically suggests lung consolidation, as might be seen with pneumonia.

A. Down B. To the left C. To the right D. Up

Correct Answer is D

Explanation

Choice A Reason:
Looking down does not typically expose the sclera and conjunctiva for examination. The lower eyelid covers more of the sclera when the eyes are directed downward, making it less accessible for observation.

Choice B Reason:
Moving the eyes to the left is not the standard direction for examining the sclera and conjunctiva. This movement would not provide an optimal view of the entire sclera and conjunctiva, as it would only stretch the lateral part of the conjunctiva.

Choice C Reason:
Directing the eyes to the right, similar to moving them to the left, does not offer the best exposure for examining the sclera and conjunctiva. The medial part of the conjunctiva would be stretched, but the rest would not be easily visible.

Choice D Reason:
Instructing the client to look up is the correct procedure when examining the sclera and conjunctiva. By looking upward, the client exposes more of the sclera and the palpebral conjunctiva, allowing the nurse to inspect these areas thoroughly for any abnormalities such as redness, swelling, or foreign bodies.

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During a comprehensive health history, a client reports coming into the hospital because he "feels like an elephant is sitting on his chest." The nurse will document this information in which of the following sections?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a respiratory system physical examination. To assess the resonance of voice sounds heard during auscultation of the lungs, the nurse instructs the patient to say "ee," and if the sound is heard as "ay," this is known as:

Correct Answer is D

Explanation

When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?

Correct Answer is D

Explanation

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