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

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

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

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

Answer and Explanation

The Correct Answer is C

Choice A reason: 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

Choice B reason: Documenting at the nursing station may delay entry, increase the risk of errors or omissions, and reduce the opportunity for immediate clarification with the client. It is less ideal for capturing nuanced or time-sensitive information.

Choice C reason: 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.

Choice D reason: Subjective data should be documented in the appropriate structured fields of the electronic medical record, not just in free-text note sections. This ensures the data is searchable, standardized, and usable for clinical decision-making and continuity of care.

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Correct Answer is D

Explanation

A. This is not specific for egophony. While lung auscultation is part of a thorough assessment, egophony is assessed when the patient vocalizes a specific sound, not just breathing in and out.
B. This is a technique used to assess for whispered pectoriloquy, not egophony. The nurse would be looking for clarity of the whispered words, which is different from assessing for egophony.
C. This test is used to assess for bronchophony, where the nurse listens for clarity or increased volume of spoken words over the lungs. It is not related to egophony, which is a change in the sound when the client says "E."
D. This is the correct method for assessing egophony. In this test, the client is asked to say "E," and the nurse listens for any change in the sound. Normally, the "E" should sound like "E." If it sounds like "A," it indicates egophony, which can suggest a lung consolidation, such as might occur with a lung abscess.

A. Morning stiffness quickly resolves B. Small joints of the hand C. Fatigue and fever D. Joint swelling E. Heberden nodes F. Symmetrical involvement G. Pain increases with motion

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

Morning stiffness quickly resolves:

Rheumatoid Arthritis: Morning stiffness is a hallmark of rheumatoid arthritis, although it typically lasts more than just a brief period.

Small joints of the hand:

Rheumatoid Arthritis: Rheumatoid arthritis commonly affects the small joints of the hands and wrists, leading to pain, stiffness, and swelling.

Fatigue and fever:

Rheumatoid Arthritis: Systemic symptoms like fatigue and low-grade fever are often associated with rheumatoid arthritis due to its inflammatory nature.

Joint swelling:

Rheumatoid Arthritis: Swelling of the joints is a key symptom of rheumatoid arthritis, typically due to inflammation and fluid accumulation within the joint.

Heberden nodes:

Not Applicable: Heberden nodes are associated with osteoarthritis, not rheumatoid arthritis. These nodes occur at the distal interphalangeal joints.

Symmetrical involvement:

Rheumatoid Arthritis: One of the classic features of rheumatoid arthritis is symmetrical involvement of joints, particularly in the hands and wrists.

Pain increases with motion:

Rheumatoid Arthritis: Joint pain that increases with motion is a common symptom of rheumatoid arthritis, reflecting active inflammation in the joints.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?

Correct Answer is D

Explanation

Patient Data Exhibits Nurse analyzes the assessment findings. Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

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