Nokea
History and Physical
Nurse's Notes
Orders
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.
For each client statement, click to highlight the statement(s) below that require follow-up teaching by the nurse.
- A. This diagnosis means that I am crazy.'
- B. I can learn to manage my thoughts better through therapy.'
- C. I can use holistic approaches like meditation to help my symptoms.'
- D. Many people have the same response to a stressful situation as I am having right'
- E. I am at high risk for post-traumatic-stress disorder because I have acute stress disorder'
- F. I will probably need to be on medication for the rest of my life.'
Correct Answer: A,C,D,F
Rationale: Statements about being 'crazy,' typical stress responses, holistic approaches, and lifelong medication need clarification to address stigma, variability in trauma responses, and treatment plans.
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A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
- A. Use an incentive spirometer.
- B. Monitor the urinary stream for the decrease in output.
- C. Report when hematuria becomes pink-tinged.
- D. Restrict physical activities.
Correct Answer: C
Rationale: Reporting pink-tinged hematuria is critical to monitor for complications post-TUNA. Spirometry, urinary stream monitoring, and activity restriction are not specific to TUNA discharge.
A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?
- A. I just feel like my life is filled with emptiness.'
- B. I have three firearms locked in a safe at home.'
- C. My daughter is the only reason I keep trying.'
- D. My panic attacks happen once every month.'
Correct Answer: B
Rationale: Access to firearms is a significant risk factor for suicide, making it critical to document. Other comments are relevant but less urgent.
The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?
- A. Encourage the mother to write thoughts and feelings in a journal.
- B. Determine if the mother has other children who do not have developmental disabilities.
- C. Reassure the mother that her child will achieve some growth and development milestones.
- D. Ask the mother if she has ever thought about harming herself or her child.
Correct Answer: D
Rationale: Asking about thoughts of self-harm or harm to the child assesses the severity of depression and risk, a critical first step. [Note: Document incorrectly lists A; D is more appropriate for safety.]
A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?
- A. Ecchymotic blood accumulations.
- B. Evidence of patches of lost hair.
- C. Episodic complaints of pruritus.
- D. Erythema of the localized lesions.
Correct Answer: A
Rationale: Ecchymotic blood accumulations (bruises) suggest trauma or physical manipulation, indicating non-disease-related hair loss. Patches of hair loss, pruritus, or erythema could be associated with medical conditions like alopecia or inflammation.
The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?
- A. Sweet potatoes.
- B. Spinach salad.
- C. Bananas.
- D. Fish.
Correct Answer: B
Rationale: Spinach is high in oxalates, contributing to calcium oxalate stone formation. Sweet potatoes, bananas, and fish are generally safe.