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 A

Explanation

A. Multiple maculopapular pustules over the forehead and chin are suggestive of acne vulgaris or possibly another dermatologic condition that may require medical intervention. If the pustules are widespread or persistent, it should be reported for further evaluation.
B. Bilateral patellar abrasions with eschar formation are common in children and are usually non- threatening unless there are signs of infection. This finding may not require immediate reporting unless the condition worsens.
C. A red, swollen, painful nodule on the upper back is likely a boil or abscess, but it’s important to consider the overall presentation and if there is a risk for systemic infection. This may not need immediate reporting unless symptoms worsen.
D. Small, white flecks on the hair shafts indicate possible head lice, which, while needing treatment,
doesn’t require immediate reporting unless there is a larger health concern associated with it.

A. Blowing, hollow sounds above sternum. B. Slight crackling throughout lung fields. C. Faint whistling over both lung bases. D. Right breath sounds louder than left.

Correct Answer is D

Explanation

A. Blowing or hollow sounds above the sternum are abnormal and may suggest a condition like aortic or pulmonary disease. Such sounds are not typical during routine chest auscultation and may indicate pathology like bronchial obstruction or an abnormal vascular sound.
B. Slight crackling sounds, also known as "rales" or "crackles," may be indicative of fluid accumulation in the lungs, often seen in conditions like pneumonia or congestive heart failure. These are not considered normal findings and warrant further evaluation.
C. Faint whistling sounds may be indicative of wheezing, which is often a sign of airway narrowing or obstruction, as seen in asthma or chronic obstructive pulmonary disease (COPD). Wheezing is not typically considered normal and should be investigated further.
D. Right-sided breath sounds being louder than the left could be a normal finding in certain individuals, depending on factors like body position or anatomical variations. In a healthy individual, this difference may not indicate pathology unless associated with other symptoms such as asymmetry in lung sounds or dyspnea.

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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?

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Naxlex Comprehensive Predictor Exams

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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?