What information would the nurse document regarding a patient's reported allergies? Select all that apply.
Family history of allergies.
Type of allergic reaction.
Medication names.
Epi Pen use for allergic reactions.
Date of allergic reaction.
Correct Answer : B,C,D,E
Choice A rationale
Documenting a family history of allergies is important for a complete health history, but it is not a direct documentation of the patient's own reported allergies. The question asks what information to document regarding a patient's reported allergies, so the focus is on the patient's personal experience, not that of their family.
Choice B rationale
The type of allergic reaction is crucial information to document. This helps in distinguishing between a true anaphylactic reaction and a side effect or intolerance. Documenting the specific signs and symptoms, such as rash, hives, or shortness of breath, provides vital information for preventing future exposures and guiding appropriate treatment if one occurs.
Choice C rationale
The medication names are essential to document to prevent future exposure to the same drug. This ensures that the patient does not receive the offending medication again, which is a primary safety measure. It is a fundamental component of a complete allergy record to specify the substance that caused the reaction.
Choice D rationale
Documentation of Epi Pen use is critical as it indicates a severe, anaphylactic reaction requiring an emergency intervention. This information alerts providers to the high risk of a life-threatening allergic response and the need for preparedness, such as having epinephrine available for future exposure.
Choice E rationale
The date of the allergic reaction should be documented to provide a chronological history. This helps in understanding the timeline of the allergy and can be useful for determining if an allergy has changed over time or for correlating the reaction with a specific exposure
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This response is dismissive and does not address the patient's concerns. Providing accurate information empowers the patient to make informed decisions about their health. The nurse should always address patient concerns and provide education, especially when it relates to their birth experience and future reproductive health. Failing to do so can erode trust and negatively impact the patient-provider relationship.
Choice B rationale
This statement is an oversimplification and potentially inaccurate. The feasibility of a vaginal birth after a cesarean section (VBAC) depends on several factors, including the type of uterine incision. A classical vertical incision, for instance, is a strong contraindication due to a significantly increased risk of uterine rupture in subsequent pregnancies. The nurse must provide a more nuanced and accurate explanation.
Choice C rationale
This is an incorrect and potentially harmful statement. A previous cesarean section does not automatically preclude a future vaginal delivery. A vaginal birth after cesarean (VBAC) is a viable option for many individuals, particularly those who had a low transverse uterine incision. The decision is based on a careful assessment of risks and benefits with the patient's provider.
Choice D rationale
This statement is the most accurate and scientifically grounded response. The type of uterine incision is the most significant factor determining the safety of a future vaginal delivery. A low transverse incision has a lower risk of rupture during a trial of labor, making VBAC a safe option for many. A classical (vertical) incision, conversely, carries a high risk of uterine rupture, necessitating a repeat cesarean.
Correct Answer is D
Explanation
Choice A rationale
Painting a picture requires fine motor skills and a level of artistic expression that may be beyond a typical toddler's developmental stage. While some toddlers may enjoy making marks on paper, the structured activity of painting a picture is more appropriate for preschoolers. Toddlers are still developing hand-eye coordination and may become frustrated with a task that requires precision.
Choice B rationale
Playing peek-a-boo is a game typically enjoyed by infants who are learning about object permanence. While a toddler may still find it amusing, it is not the most developmentally appropriate activity for a hospitalized toddler who is developing gross motor skills, independence, and exploring their environment. The game does not support the toddler's need for autonomy and movement.
Choice C rationale
Listening to music can be a soothing and pleasant activity for a toddler, especially in a hospital setting. However, it is a passive activity. The most appropriate play for a toddler is one that engages their newfound gross motor skills, sense of autonomy, and exploration. A passive activity like listening to music does not fully meet the developmental needs of this age group.
Choice D rationale
Playing with a push-pull toy is the most appropriate activity for a toddler. Toddlers are in the developmental stage of mastering walking and running. These toys support the development of gross motor skills, coordination, and balance. The activity also encourages independent exploration and a sense of mastery, which aligns with the toddler's psychosocial stage of autonomy versus shame and doubt.
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