During a comprehensive health history, a client reports coming into the hospital because he "feels like an elephant is sitting on his chest." The nurse will document this information in which of the following sections?

Family History

Past Medical History

Chief Complaint

Present Illness

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Family History is used to document health events in the patient's family, including diseases that may be hereditary or place the patient at risk. The statement about feeling like an elephant is sitting on the chest is not related to family health but is a description of the patient's current symptoms.

Choice B Reason:
Past Medical History includes information about the patient's past health issues, surgeries, hospitalizations, allergies, and treatments. It does not include current symptoms or the reasons for the current hospital visit.

Choice C Reason:
The Chief Complaint is the section where the nurse documents the primary reason for the patient's visit in their own words. The phrase "feels like an elephant is sitting on his chest" is a classic description of chest pain or discomfort, often associated with cardiac issues, and would be documented here as it represents the patient's main concern.

Choice D Reason:
Present Illness or History of Present Illness would include a detailed account of the development of the patient's illness or health concern. While it is closely related to the Chief Complaint, it is more detailed and includes the onset, duration, and character of the symptoms, among other aspects. The initial statement would be part of the Chief Complaint, which leads into the more detailed History of Present Illness.

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Correct Answer is A

Explanation

Choice A Reason:
This approach is recommended as it allows for a systematic comparison between the two sides of the chest. Percussion should start at the apices of the lungs, which are located just above the clavicles, and proceed downwards. This method ensures that any differences in percussion note, which could indicate underlying pathology, are identified by direct comparison.

Choice B Reason:
While this approach also involves a systematic assessment, it does not allow for immediate comparison between the two sides of the chest. It is important to compare corresponding areas on each side as you go to detect any asymmetry or changes in resonance.

Choice C Reason:
This method, similar to choice B, does not facilitate immediate side-to-side comparison during the assessment. Immediate comparison is crucial for identifying subtle differences that may indicate conditions such as pleural effusion or pneumothorax.

Choice D Reason:
Starting the percussion above the left clavicle and moving to the right chest after completing the left side does not allow for direct comparison of symmetrical chest areas. Additionally, assessing the right chest moving upward from the liver is not a standard practice, as the liver dullness can interfere with the percussion of the lower right lung fields.

A. Vertigo B. Rhinorrhea C. Fever D. Headache

Correct Answer is A

Explanation

Choice A Reason:
Vertigo is a common complication associated with inner ear infections, such as labyrinthitis or vestibular neuritis. The inner ear is responsible for balance, and when it is infected, it can lead to a sensation of spinning or dizziness. Interventions may include medications like meclizine or dimenhydrinate to alleviate symptoms, as well as safety measures to prevent falls.

Choice B Reason:
Rhinorrhea, or a runny nose, is not typically a direct complication of an inner ear infection. It may be associated with upper respiratory infections that can precede or accompany an ear infection but is not a result of the inner ear infection itself.

Choice C Reason:
Fever may be present if the inner ear infection is part of a systemic infection, such as the flu or bacterial meningitis. However, fever is not a direct result of an isolated inner ear infection. If fever is present, the nurse should monitor the patient's temperature and may administer antipyretics as ordered.

Choice D Reason:
Headache can be a symptom experienced by individuals with inner ear infections due to the general discomfort and pressure changes in the ear. However, it is not as specific or as common as vertigo when it comes to inner ear infections. If headaches are present, pain management strategies can be included in the care plan.

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During a comprehensive health history, a client reports coming into the hospital because he "feels like an elephant is sitting on his chest." The nurse will document this information in which of the following sections?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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