The student nurse is reviewing different types of health history. Which client situation would require an Emergency health history?
A client who has recently been diagnosed with a chronic illness.
A client with hypotension, tachycardia, SpO2 85%, and a recent gunshot wound.
A client who just confirmed she is pregnant.
A client who makes frequent hospital visits reporting the same symptom.
The Correct Answer is B
Choice a reason:
A client recently diagnosed with a chronic illness would require a comprehensive health history that includes past medical history, medications, and lifestyle factors. While important, it is not typically categorized as an emergency health history unless the chronic condition has acutely worsened.
Choice b reason:
A client presenting with hypotension (low blood pressure), tachycardia (rapid heart rate), an oxygen saturation of 85% (indicating potential hypoxemia), and a recent gunshot wound is experiencing a life-threatening situation that requires immediate medical attention. An Emergency health history is crucial in this scenario to quickly gather information that will guide urgent treatment decisions.
Choice c reason:
A client who has just confirmed pregnancy would need a detailed health history, including obstetric and gynecological history, but this is not considered an emergency unless there are complications or concerns that require immediate attention.
Choice d reason:
A client who frequently visits the hospital reporting the same symptom may indicate a chronic issue that needs ongoing management rather than an emergency. However, if the symptom suggests an acute exacerbation or a new, serious condition, it could escalate to an emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The primary purpose of health assessment is to collect, analyze, and interpret data to identify the patient’s health status and needs, as well as to develop and implement appropriate nursing interventions to address these needs. It is a systematic process that is fundamental in promoting the health and well-being of patients. This involves a comprehensive evaluation of the patient's physical, psychological, and social health. Gathering this information is crucial for creating a care plan that addresses the individual needs of the client.
Choice B reason:
While health assessments can aid physicians in diagnosing illness, they are not solely for the purpose of diagnosis without further testing. Health assessments may indicate the need for additional tests to confirm a diagnosis. The nurse's role includes supporting the diagnostic process, but it is not the primary purpose of health assessment.
Choice C reason:
Health assessments are not meant to be subjective or based on the nurse's personal views and beliefs. The assessments are conducted to objectively determine the health status of a client, which then informs evidence-based practice and care planning. Personal biases should not influence the management of a client's illness.
Choice D reason:
Making judgments about a client's lifestyle and behaviors is not the primary purpose of health assessment. While lifestyle and behaviors may be assessed as part of understanding the client's overall health status, the goal is not to judge but to understand how these factors may impact the client's health and to provide education and support for healthy changes if needed.
Correct Answer is C
Explanation
Choice A Reason:
Palpitations are typically associated with hyperthyroidism, not hypothyroidism. They occur due to an excess of thyroid hormones, which can overstimulate the heart, leading to increased heart rate and palpitations. In hypothyroidism, the heart rate is usually slower, and palpitations are less common.
Choice B Reason:
Diaphoresis, or excessive sweating, is also more commonly associated with hyperthyroidism. In hypothyroidism, the metabolism is slowed down, which reduces the tendency for increased sweating. Patients with hypothyroidism may actually have less sweating than normal.
Choice C Reason:
Weight gain is a common symptom of hypothyroidism. Due to the decreased metabolic rate caused by low levels of thyroid hormones, the body burns fewer calories, which can lead to weight gain. This is one of the hallmark signs of hypothyroidism and is often one of the first symptoms patients notice.
Choice D Reason:
Exophthalmos, the protrusion of the eyes, is a symptom associated with Graves' disease, a form of hyperthyroidism. It is not a symptom of hypothyroidism. In hypothyroidism, any eye changes are usually related to puffiness or edema around the eyes, not the bulging of the eyes themselves.
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