A nurse in the ER is caring for a patient who had fallen at home. She reviews the blood pressure reading of 160/80 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?

Ask the client if she is having pain

Request a prescription for an antianxiety medication

Request a prescription for an antihypertensive medication

Return in 30 min to recheck the client’s blood pressure

Answer and Explanation

The Correct Answer is A

A. Ask the client if she is having pain.

This option recognizes the potential relationship between pain and elevated blood pressure. Assessing the client for pain is crucial, as pain can contribute to increased blood pressure.

B. Request a prescription for an antianxiety medication.

This option assumes that anxiety might be the cause of the elevated blood pressure. However, without further assessment, it may not be appropriate to jump to prescribing medication for anxiety.

C. Request a prescription for an antihypertensive medication.

Initiating antihypertensive medication without further assessment may not be the most appropriate first step, especially if the elevated blood pressure is related to pain or another temporary factor.

D. Return in 30 minutes to recheck the client’s blood pressure.

While monitoring blood pressure is important, waiting 30 minutes without further assessment or intervention might delay addressing the underlying issue, especially if it is related to pain or another acute problem.

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Correct Answer is D

Explanation

A. He has an electrical burn, which caused coagulation of some tissues:

This response provides more detailed information about the nature of the electrical burn, mentioning tissue coagulation. However, it may be more information than the family needs at this point, and it's important to balance providing information with respecting the client's privacy.

B. He is doing well, although he might be in the hospital for some time:

While this response aims to reassure the family about the client's general status, it might not be entirely accurate or provide specific information about the client's condition. It's important to be transparent while respecting the client's privacy.

C. He does not appear to have much damage and should be fine soon:

This response may provide a sense of reassurance to the family, but it might oversimplify the situation. It's important to provide accurate and honest information while respecting the client's privacy.

D. He has an electrical burn. He is stable, and we will update you with any changes:

This response acknowledges the type of injury, assures the family that the client is stable, and communicates a commitment to keeping the family informed of any changes. It strikes a balance between providing some information and maintaining the client's privacy and confidentiality.

A. Documentation is a communication tool for the interprofessional health care team B. Documentation allows providers to monitor the nurse’s activities C. Documentation provides information to the client about financial charges. D. Documentation provides information for a client audit

Correct Answer is A

Explanation

A. Documentation is a communication tool for the interprofessional health care team

The purpose of documentation in the electronic health record (EHR) includes serving as a communication tool among members of the interprofessional healthcare team. Accurate and timely documentation allows healthcare providers to share information about the client's care, treatment, and outcomes.

B. Documentation allows providers to monitor the nurse’s activities:

While documentation provides a record of the nurse's activities, the primary purpose is to communicate information about patient care rather than serving as a tool for monitoring the nurse's activities.

C. Documentation provides information to the client about financial charges:

The primary purpose of documentation is to record and communicate information about the client's health status, care, and outcomes. Financial information is typically managed separately from clinical documentation.

D. Documentation provides information for a client audit:

While documentation can be used in audits for quality assurance, the primary purpose is to record and communicate information about patient care. The use of documentation for audits is a secondary function related to quality improvement and regulatory compliance.

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A nurse in the ER is caring for a patient who had fallen at home. She reviews the blood pressure reading of 160/80 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is orienting a newly licensed nurse about documentation of a client’s information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

Correct Answer is A

Explanation

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