The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

Enter subjective data in the note section of the client's electronic medical record.

Document the client's history that is directly related to current admission diagnoses.

Enter the information in the electronic medical record at the client's bedside.

Document the assessment findings on the computer at the nursing station.

Answer and Explanation

The Correct Answer is B

A.   While subjective data is important, it should be categorized appropriately based on relevance to the diagnosis, not just placed in the notes section without context.
B.   Documenting the client’s history directly related to the current admission diagnoses ensures the information is relevant and addresses the issue at hand. It helps prioritize concerns specific to the new onset seizures.
C.   Recording at the bedside can be useful for accuracy but is not as effective for thoroughness as
entering information directly in the client’s electronic medical record with appropriate organization.
D.   Documenting assessment findings at the nursing station might delay real-time recording and cause the information to be less accurate, especially if not recorded immediately after assessment.

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Correct Answer is D

Explanation

A. This is not applicable in this case. A BMI of 14 kg/m² indicates severe malnutrition, not excess nutrition. The client is at risk for nutritional deficiencies, not an excess of nutrition.
B. While fluid volume might be a concern in severely malnourished clients, the primary issue in this scenario is related to nutrition rather than fluid imbalance. A low BMI suggests insufficient caloric intake.
C. Excess fluid volume is not typically associated with a low BMI. In fact, clients with a BMI this low may show signs of dehydration or fluid loss due to inadequate nutritional intake.
D. This is the most appropriate nursing diagnosis. A BMI of 14 kg/m² is indicative of severe malnutrition and the client is not meeting their nutritional needs, which could lead to further health complications.

A. Examine client's sclera for icterus. B. Review recent serum bilirubin levels. C. Observe the client's urine for dark orange color. D. Assess conjunctival sacs of lower lids for pallor.

Correct Answer is A

Explanation

A. Icterus, or yellowing of the sclera, is a key sign of jaundice, which occurs when there is an excess of bilirubin in the blood.
B. Serum bilirubin levels are important for diagnosis but are not an immediate physical assessment.
C. Dark urine can suggest liver or bile duct issues but is not definitive for jaundice.
D. Pallor of the conjunctiva indicates anemia, not jaundice.

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The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

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Naxlex Comprehensive Predictor Exams

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