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Exhibits

Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.

Occupation of legal secretary

Stiffness in hands for 3 months

Radial and pedal pulses 2+

Pain in bilateral hands and wrists

History of asthma using albuterol inhaler PRN

Capillary refill 2 seconds

Body mass index (BMI) of 31 kg/m2

Client's hobbies

Answer and Explanation

Correct Answer : A,B,D,G,H

A. Occupation of legal secretary: The client works as a legal secretary, which may involve extensive typing or repetitive hand movements. This can contribute to musculoskeletal stress or strain, potentially exacerbating symptoms like pain and stiffness in the hands.

B. Stiffness in hands for 3 months: The client reports stiffness in both hands and wrists for the past 3 months, which could suggest an inflammatory arthritis such as rheumatoid arthritis (RA). This warrants further evaluation, especially given her family history of arthritis.

C. Radial and pedal pulses 2+: A rating of 2+ for radial and pedal pulses is normal, indicating no circulation issues, and does not need further evaluation.

D. Pain in bilateral hands and wrists: Persistent, symmetrical pain in the hands and wrists, particularly with palpation, may indicate a condition like rheumatoid arthritis. This symptom, in combination with morning stiffness, needs further investigation.

E. History of asthma using albuterol inhaler PRN: The client's history of well-controlled asthma, managed with an albuterol inhaler as needed for exacerbations, does not directly relate to her current presentation of hand pain and stiffness.

F. Capillary refill 2 seconds: A capillary refill time of 2 seconds is within the normal range, indicating adequate peripheral perfusion. This finding suggests that there are no immediate circulatory issues contributing to her hand pain and stiffness and does not require further evaluation.

G. Body mass index (BMI) of 31 kg/m²: A BMI of 31 falls within the obese range, which can increase the risk for musculoskeletal issues and other chronic conditions. This factor should be evaluated further, as obesity may affect joint health.

H. Client's hobbies: The client enjoys hobbies like gardening and crocheting, which involve repetitive hand movements. These activities could exacerbate the pain and stiffness in her hands, making it important to evaluate whether these hobbies are contributing to her symptoms.

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Correct Answer is B

Explanation

A. "Yoga is not the subject of this group": This response dismisses the client's curiosity and could shut down the conversation. Shutting down the discussion abruptly can make clients feel unheard and discourage participation, hindering the therapeutic environment.

B. "What do you want to know about it?": This response validates the client's interest and encourages open discussion. The nurse can provide a brief explanation without derailing the group session.

C. "Wait, let her finish talking": This response may seem dismissive and could discourage engagement. It is important to address the interruption respectfully while also encouraging dialogue.

D. "Do not interrupt in group again": This kind of response can create a hostile environment, shut down communication, and damage the therapeutic relationship between the nurse and the clients, especially in a mental health setting where trust and open expression are vital.

A. History of hypertension. B. Family health history. C. Vegetarian diet. D. Sexual history. E. Excessive aerobic exercise.

Correct Answer is ["A","B"]

Explanation

A. History of hypertension: Although the client’s current blood pressure is controlled with atenolol, the need for medication confirms a history of hypertension. Hypertension is a major modifiable risk factor for coronary artery disease and warrants ongoing assessment.

B. Family health history: A strong family history of heart disease and diabetes, particularly in first-degree relatives, significantly increases the client’s risk for cardiovascular events. The genetic predisposition should be explored to assess early markers and implement prevention strategies.

C. Vegetarian diet: A vegetarian diet is generally associated with lower cardiovascular risk due to reduced intake of saturated fats and cholesterol. Unless the diet is poorly balanced or nutrient-deficient, it does not constitute a risk factor that requires further evaluation here.

D. Sexual history: Sexual history may be relevant in certain clinical contexts, such as evaluating HIV risk or sexually transmitted infections, but it is not directly related to the client's cardiac symptoms or concern about hereditary heart disease.

E. Excessive aerobic exercise: The client’s activity level (jogging) is not excessive and is generally healthy, unless it is associated with overtraining or extreme exertion. There is no indication here that excessive exercise is a concern, so further exploration is not needed based on this information.

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Exhibits Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mental health nurse is leading a group about relaxation and explains the benefits of deep breathing for relaxation. As a female client begins to explain how she uses yoga to relax, another client interrupts and asks, "What's yoga?" Which is the nurse's best response?

Correct Answer is B

Explanation

Correct Answer is ["A","B"]

Explanation

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Exhibits

Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.