Question

A client who is a veteran comes to the emergency department appearing tense, anxious, and having difficulty concentrating on the questions the nurse is asking

during the health history. Which client statement is most important for the nurse to document?

Answer 1

The most important statement for the nurse to document is the client reporting sensory dysfunction, as it could indicate a significant neurological or vascular issue, leading to targeted medical interventions such as a CT scan and aspirin therapy.

Step-by-step explanation:

The most important statement for the nurse to document is the client reporting pins and needles in his left arm and leg, and difficulty feeling the tip of a pen when touched on those limbs. These symptoms suggest a potential issue with the sensory systems between the spinal cord and the brain and could lead to significant diagnostic and therapeutic actions, such as a CT scan or aspirin therapy to prevent blood clots in case of an embolus. This statement, compared to the other potential concerns raised in the question, provides a clearer lead for the medical staff to pursue in order to address the client's immediate health concerns.

The underlying details of the question touch upon various aspects of the veteran's health, which includes his mental state (anxiety, tension, difficulty concentrating), but the focus here is on the clear physiological symptom of sensory perception that could signal a neural or vascular problem. Comprehensive documentation of this information is critical, as it may contribute to both the immediate and long-term management of the patient's condition.