The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

Enter subjective data in the note section of the client's electronic medical record.

Document the client's history that is directly related to current admission diagnoses.

Enter the information in the electronic medical record at the client's bedside.

Document the assessment findings on the computer at the nursing station.

Answer and Explanation

The Correct Answer is B

A.   While subjective data is important, it should be categorized appropriately based on relevance to the diagnosis, not just placed in the notes section without context.
B.   Documenting the client’s history directly related to the current admission diagnoses ensures the information is relevant and addresses the issue at hand. It helps prioritize concerns specific to the new onset seizures.
C.   Recording at the bedside can be useful for accuracy but is not as effective for thoroughness as
entering information directly in the client’s electronic medical record with appropriate organization.
D.   Documenting assessment findings at the nursing station might delay real-time recording and cause the information to be less accurate, especially if not recorded immediately after assessment.

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Correct Answer is C

Explanation

A. While this approach may seem less intrusive, it can create confusion and may prevent the client from feeling fully understood. Asking vague questions could make it more difficult to get useful information about the client's health concerns.
B. Sharing personal values is generally not appropriate in a clinical interview, as it could create boundaries that compromise the professional relationship. The nurse should maintain objectivity and empathy without sharing personal beliefs.
C. Starting with less sensitive questions allows the nurse to build rapport and trust with the client before delving into more personal or difficult topics. This approach is helpful in easing the client into more sensitive discussions.
D. Asking the most difficult questions right away can overwhelm the client, especially if they are hesitant or uncomfortable. It is better to establish a trusting relationship first and allow the client to open up at their own pace.

A. "What were you doing when you first noticed the problem?" B. "Have you taken any medications to relieve the pain?" C. "Does changing your position make the pain worse?" D. "Do you remember ever having this type of pain in the past?"

Correct Answer is A

Explanation

A. Understanding the onset and activities related to the back pain can help the nurse determine if it is musculoskeletal, posture-related, or indicative of a more serious underlying issue.
B. Asking about medication is secondary until more information is gathered about the pain's onset and nature.
C. Changing positions may be relevant later, but initially, it is important to identify any possible triggers for the pain.
D. Asking about previous pain episodes may be helpful, but understanding the current episode’s cause is more pressing.

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