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 C

Explanation

A. Pull the auricle upward and outward: While pulling the auricle upward helps straighten the external auditory canal in adults, directing it outward does not fully align the canal’s natural S-shaped curve. Proper straightening requires a backward motion to allow the medication to flow toward the tympanic membrane effectively.

B. Pull the auricle downward and backward: Pulling the auricle downward and backward is the technique used for children younger than 3 years of age. In young children, the ear canal is more horizontal, and this maneuver helps straighten it appropriately. This method is not correct for adults.

C. Pull the auricle upward and backward: In adults, the external auditory canal curves upward and posteriorly. Pulling the auricle upward and backward straightens the canal, facilitating proper instillation of the medication and ensuring it reaches the intended area near the tympanic membrane.

D. Pull the auricle downward and outward: This technique does not effectively straighten the adult ear canal. Incorrect positioning can result in medication pooling in the outer canal rather than reaching the deeper structures where therapeutic action is needed.

A. The client was discharged to home without developing complications of immobility. B. The client returned to the facility 2 days after being discharged due to a urinary tract infection. C. The client developed a rash on their back and lower extremities. D. The client refuses to eat because they are nauseated.

Correct Answer is A

Explanation

A. The client was discharged to home without developing complications of immobility: Repositioning a client every 2 hours is a key intervention to prevent pressure injuries, improve circulation, and reduce the risk of complications such as skin breakdown, deep vein thrombosis, and pneumonia. Achieving discharge without immobility-related complications indicates that preventive measures were effective.

B. The client returned to the facility 2 days after being discharged due to a urinary tract infection: Development of a urinary tract infection shortly after discharge may be related to catheter use, incontinence, or urinary stasis, but frequent repositioning does not directly prevent UTIs. This outcome suggests a complication occurred despite nursing interventions.

C. The client developed a rash on their back and lower extremities: Skin rashes may indicate irritation, allergic reactions, or moisture-associated skin damage. Repositioning helps relieve pressure and reduce friction but does not directly prevent all types of rashes. The appearance of a rash reflects a complication related to skin integrity rather than an expected outcome.

D. The client refuses to eat because they are nauseated: Nausea and refusal of food are unrelated to repositioning frequency. While immobility can contribute to gastrointestinal stasis, this outcome does not reflect the effectiveness of repositioning interventions for preventing pressure injuries or related complications.

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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?

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