The student nurse is reviewing different types of health history. Which client situation would require an Emergency health history?

A client who has recently been diagnosed with a chronic illness.

A client with hypotension, tachycardia, SpO2 85%, and a recent gunshot wound.

A client who just confirmed she is pregnant.

A client who makes frequent hospital visits reporting the same symptom.

Answer and Explanation

The Correct Answer is B

Choice a reason:
A client recently diagnosed with a chronic illness would require a comprehensive health history that includes past medical history, medications, and lifestyle factors. While important, it is not typically categorized as an emergency health history unless the chronic condition has acutely worsened.

Choice b reason:
A client presenting with hypotension (low blood pressure), tachycardia (rapid heart rate), an oxygen saturation of 85% (indicating potential hypoxemia), and a recent gunshot wound is experiencing a life-threatening situation that requires immediate medical attention. An Emergency health history is crucial in this scenario to quickly gather information that will guide urgent treatment decisions.

Choice c reason:
A client who has just confirmed pregnancy would need a detailed health history, including obstetric and gynecological history, but this is not considered an emergency unless there are complications or concerns that require immediate attention.

Choice d reason:
A client who frequently visits the hospital reporting the same symptom may indicate a chronic issue that needs ongoing management rather than an emergency. However, if the symptom suggests an acute exacerbation or a new, serious condition, it could escalate to an emergency.

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Correct Answer is C

Explanation

Choice a reason:
Objective data refers to information that is observable and measurable by the healthcare provider, such as vital signs, physical examination findings, and laboratory results. The patient's statements about his feelings are not objective data because they cannot be directly measured or observed by the nurse.

Choice b reason:
Introspective data is not a commonly used term in healthcare. Introspection generally refers to the examination of one's own conscious thoughts and feelings, which in the context of healthcare, can be part of subjective data as it is reported by the patient.

Choice c reason:
Subjective data consists of information that is reported by the patient, including feelings, perceptions, and concerns. It is called 'subjective' because it is based on the patient's personal experience and cannot be independently verified by the nurse. In this case, the patient's report of feeling anxious, nauseated, and hot is considered subjective data.

Choice d reason:
Reflective data is not a standard term in healthcare documentation. Reflection is a process of personal thought and does not pertain to the clinical data gathered during a patient assessment.

A. The immunization schedule recommended for the client's age. B. The need for regular mammogram screening to identify breast cancer lesions. C. The need for consistent use of seat belts when in a motor vehicle. D. The impact of annual vision examinations on personal health and safety.

Correct Answer is B

Explanation

Choice a reason:
Immunization schedules are typically considered a part of primary prevention. They are intended to prevent diseases before they occur by using vaccines to provide immunity against infections.

Choice b reason:
Regular mammogram screenings are a form of secondary prevention. They are used to detect breast cancer lesions early before symptoms appear, which can lead to more effective treatment and better outcomes.

Choice c reason:
The consistent use of seat belts is a primary prevention strategy. It is a proactive measure to prevent injuries in the event of a motor vehicle accident.

Choice d reason:
Annual vision examinations can be considered part of secondary prevention if they are used to detect vision problems or eye diseases in their early stages. However, they can also be seen as primary prevention because they help maintain and protect eye health before issues arise.

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The student nurse is reviewing different types of health history. Which client situation would require an Emergency health history?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 17-year-old male patient presents to the Emergency Department (ED) after a skydiving accident and tells the nurse that he is very anxious, is nauseated, and feels hot. These types of data would be:

Correct Answer is C

Explanation

While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

Correct Answer is B

Explanation

A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. Which problem should the nurse document?

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?

A client has been receiving intravenous antibiotics (ototoxic) for several weeks. Which prevention strategy would be best for the nurse to recommend for this client?

The nurse is using the finger pads of the hand to palpate a body part. Which finding would the nurse be best able to detect?

Using the client's height of 72 inches and weight of 200 lbs, the nurse calculates the BMI. A BMI of 27 indicates which category for this patient?

The nurse knows the importance of assessing vital signs is to:

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