The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

"The care team needs to cross-reference your diagnostic testing with your medical history."

"In general, it's necessary for us to gather as much information about each client as possible."

"We do not want to focus solely on the medical problem that brought you here."

"This information will help me to plan individualized nursing care with you."

Answer and Explanation

The Correct Answer is D

A. While diagnostic testing and medical history are important, this response does not acknowledge the client’s frustration or emphasize the purpose of the assessment.
B. This response is too general and does not provide reassurance to the client.
C. While this statement is true, it does not clearly explain why the history is necessary in a way that involves the client.
D. "This information will help me to plan individualized nursing care with you" is correct because it directly explains the purpose of the assessment and involves the client in their care.

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Correct Answer is B

Explanation

A. A 3-year-old with fever, rash, and sore throat should be evaluated promptly, but these symptoms do not necessarily indicate an immediate life-threatening emergency.
B. A 45-year-old man with chest pain and diaphoresis for 1 hour is the priority because these are classic symptoms of acute coronary syndrome (ACS) or myocardial infarction (MI). Immediate emergency assessment and intervention are required.
C. A 14-year-old girl crying about a possible pregnancy needs emotional support and counseling but does not require immediate emergency intervention.
D. A 20-year-old man with a 3-inch shallow laceration on his leg needs wound care, but his condition is not life-threatening and does not require emergency assessment.

A. Papule B. Crust C. Bulla D. Vesicle

Correct Answer is D

Explanation

A. A papule is a small, raised lesion that is solid and does not contain fluid, which is not characteristic of shingles.
B. A crust forms as a lesion heals but is not the primary lesion seen in shingles.
C. A bulla is a large, fluid-filled lesion seen in conditions like burns or insect bites, but shingles lesions are typically smaller.
D. A vesicle is correct. Shingles (herpes zoster) presents with clusters of vesicles on an erythematous base, typically in a unilateral, dermatomal pattern. These vesicles are filled with clear fluid and become pustular before crusting over.

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The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

Correct Answer is B

Explanation

An older adult client reports that they are experiencing severe trunk pain and is concerned that it might be shingles. Which type of lesion would the nurse most likely assess if shingles were present?

Correct Answer is D

Explanation

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