A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?

Chart a summary of the data at the change of the shift.

Note whether the client has a living will.

Document the client's vital signs obtained by assistive personnel.

Begin charting with an evaluation of the data.

Answer and Explanation

The Correct Answer is D

A. Chart a summary of the data at the change of the shift - Documenting a summary of data at the change of shift is appropriate for communication among healthcare providers but should not be the first action. It's important to document all relevant admission data promptly and accurately.
B. Note whether the client has a living will - While documenting the client's living will status is important for their care, it's not the first action to take during admission documentation. Immediate assessment and documentation of essential data related to the client's condition and history take priority.
C. Document the client's vital signs obtained by assistive personnel - Documenting vital signs obtained by assistive personnel is appropriate, but it should not be the first action. The nurse should first conduct a comprehensive assessment and document all relevant admission data.
D. Begin charting with an evaluation of the data - This is the most appropriate action. The nurse should start by evaluating and documenting the admission data systematically and comprehensively. This includes the client's chief complaint, medical history, allergies, current medications, vital signs, physical assessment findings, and any other pertinent information. Starting with an evaluation ensures that all relevant data are captured and documented accurately.

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Correct Answer is C

Explanation

A. "Hold your daughter when your son first meets her." While it is important for the mother to hold the newborn during the first meeting with the older sibling, this option does not directly address the preschool-age son's potential reaction to the new baby.
B. "Plan for your son to meet his sister for the first time at home." Planning for the first meeting to occur at home is a common and appropriate strategy to help ease the transition for the older sibling. However, this option does not provide a specific strategy for helping the preschool-age son adjust to having a new sister.
C. "Give your son a little gift from his new sister." This is the most appropriate strategy to suggest. Offering a small gift from the new baby sister can help the preschool-age son feel included and special, fostering positive feelings toward the new sibling.
D. "Give your son plenty of 'alone time' with his sister." While encouraging bonding time between siblings is important, giving the older sibling plenty of alone time with the new baby may not be practical or feasible, especially in the early postpartum period when the mother requires assistance with caring for the newborn. Moreover, this option does not address the son's potential feelings of adjustment to having a new sister.

A. "You might feel a bit confused for a few hours after the procedure." B. "You might notice some changes in your-voice after the procedure." C. "You'll wake up about 30 minutes after the procedure." D. "You can expect to feel some pulsation's in your neck during the procedure."

Correct Answer is A

Explanation

A. "You might feel a bit confused for a few hours after the procedure": Confusion is a common side effect of electroconvulsive therapy (ECT) immediately following the procedure. It typically resolves within a few hours as the effects of anesthesia wear off. Providing this information prepares the client for potential post-procedure effects.
B. "You might notice some changes in your voice after the procedure": Changes in voice are not typically associated with ECT. Therefore, this statement is not relevant to the client's education about what to expect during or after the procedure.
C. "You'll wake up about 30 minutes after the procedure": The duration of unconsciousness following ECT can vary from person to person. While clients typically awaken within minutes after the procedure, specifying a time frame of 30 minutes may not accurately reflect individual experiences.
D. "You can expect to feel some pulsations in your neck during the procedure": Feeling pulsations in the neck is not a common sensation experienced during ECT. This statement does not accurately describe the procedure or its associated sensations.

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A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?

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