Prior to taking the health history, the nurse should first do which of the following?

Offer the client a beverage of choice

Establish that insurance coverage exists

Establish a rapport with the patient

Ask the patient to disrobe and put on a gown

Answer and Explanation

The Correct Answer is C

Choice A reason: Offering a beverage is a hospitable gesture but not the first step in taking a health history. The priority is to establish communication and trust.

Choice B reason: Confirming insurance coverage is important but not the initial step in the health history process. The focus should first be on the patient's immediate needs and concerns.

Choice C reason: Establishing a rapport with the patient is the first and most crucial step in taking a health history. It involves creating a comfortable and trusting environment for the patient to share personal health information.

Choice D reason: Asking the patient to disrobe and put on a gown may be necessary for a physical examination but is not the first step in taking a health history. The nurse should first establish a rapport with the patient.

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Correct Answer is A

Explanation

Choice A reason: The carotid pulse sites should not be checked bilaterally at the same time because palpating both carotid arteries simultaneously can restrict blood flow to the brain and may also stimulate the vagus nerve, potentially causing bradycardia or even syncope.

Choice B reason: The popliteal pulse, located at the back of the knee, can be checked bilaterally without the risk of restricting blood flow to vital organs or stimulating a vagal response.

Choice C reason: The femoral pulse, found in the groin area, can also be checked bilaterally as it does not pose the same risks as the carotid pulse when checked simultaneously.

Choice D reason: The brachial pulse, located on the inside of the arm just above the elbow, is another site that can be checked bilaterally without significant risk.

A. Pulse 82/min, client sitting in a chair B. Temperature 36.9°C (98.4°F) C. Respirations auscultated, even at 22/min, client supine D. Blood pressure 108/68 mm Hg

Correct Answer is A

Explanation

Choice A reason: Documenting the pulse as "82/min, client sitting in a chair" is correct and shows an understanding of the teaching. The pulse rate is within the normal range for a resting adult, which is typically between 60 to 100 beats per minute. Additionally, noting the client's position is important as body position can affect pulse rate; sitting can slightly increase the pulse compared to lying down.

Choice B reason: The temperature of "36.9°C (98.4°F)" is within the normal range for body temperature, which is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F). Documenting the temperature in both Celsius and Fahrenheit is a good practice, as it provides clarity and prevents confusion in clinical settings where different systems may be used.

Choice C reason: The documentation of respirations as "auscultated, even at 22/min, client supine" is appropriate. The normal respiratory rate for a healthy adult at rest is between 12 to 20 breaths per minute. Noting that the respirations are even and the client's position is supine is important, as different positions can affect breathing patterns and rates.

Choice D reason: A blood pressure reading of "108/68 mm Hg" falls within the normal range, which is generally considered to be between 90/60 mm Hg and 120/80 mm Hg for adults. Proper documentation of blood pressure includes both systolic and diastolic values, as seen here, which is essential for accurate monitoring and treatment decisions.

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