A nurse on a mental health unit is collecting data from a newly admitted client. Which of the following information should the nurse document as part of the client's medical history?

Consumes foods with purines

Hospitalized for bipolar disorder 2 years ago

Step-sister has major depressive disorder

Plans to start group therapy sessions once per week

Answer and Explanation

The Correct Answer is B

A. Consumes foods with purines: Dietary habits may be relevant for certain conditions, such as gout, but consumption of purine-rich foods is not part of the client’s medical history. It is considered current lifestyle information rather than past or ongoing medical diagnoses.

B. Hospitalized for bipolar disorder 2 years ago: Previous hospitalizations for psychiatric conditions are a key component of the client’s medical history. This information provides context for current mental health status, risk assessment, and planning of care, and helps identify patterns in symptom management and treatment response.

C. Step-sister has major depressive disorder: Family history is important and documented separately under genetic or familial risk factors. While it informs potential predisposition, it does not constitute the client’s personal medical history.

D. Plans to start group therapy sessions once per week: Future intentions or planned interventions reflect care planning and goals rather than historical medical data. This information is documented in the plan of care rather than the medical history section.

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Correct Answer is B

Explanation

A. Oral irrigating device: An oral irrigating device is used for oral hygiene but is not a priority for a client with bacterial meningitis. Infection control and safety interventions take precedence over routine hygiene equipment upon admission.

B. Seizure pads: Clients with bacterial meningitis are at risk for increased intracranial pressure and seizures due to inflammation of the meninges. Placing seizure pads on the bed helps prevent injury if a seizure occurs, ensuring client safety during acute illness.

C. Sterile gloves: Standard precautions require the use of clean gloves for routine care. Sterile gloves are necessary only for invasive procedures, not for general admission care, so they are not a priority item for the room setup.

D. Tongue blade: A tongue blade is used for throat examinations but is not essential for immediate care of a client with bacterial meningitis. Priority interventions focus on monitoring neurologic status and preventing complications such as seizures.

A. Pour liquid by holding the bottle with the label facing the sterile field. B. Prepare the sterile field 5 cm (2 in) below the level of the waist. C. Pour liquids from 10 to 15 cm (4 to 6 in) above the sterile field. D. Open the outermost flap of the wrapper toward the body.

Correct Answer is C

Explanation

A. Pour liquid by holding the bottle with the label facing the sterile field: When pouring solutions onto a sterile field, the label should face the nurse’s hand, not the sterile field. This prevents the liquid from running down the bottle and obscuring or washing off the label, which maintains accurate identification of the solution while protecting the sterile field.

B. Prepare the sterile field 5 cm (2 in) below the level of the waist: The sterile field should be set up at or above waist level to prevent accidental contamination. Positioning it below waist level increases the risk of droplets, contact with nonsterile surfaces, or accidental touches, compromising sterility.

C. Pour liquids from 10 to 15 cm (4 to 6 in) above the sterile field: Maintaining this distance ensures that the fluid is poured without splashing or touching the sterile field with the bottle, which reduces contamination risk. This technique balances control and safety while preserving sterility during preparation or dressing changes.

D. Open the outermost flap of the wrapper toward the body: The outermost flap should be opened away from the body to prevent reaching over the sterile field, which could result in accidental contamination. Opening toward the body increases the chance that clothing or hands might contact the sterile surface.

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A nurse on a mental health unit is collecting data from a newly admitted client. Which of the following information should the nurse document as part of the client's medical history?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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