Author Question: The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible ... (Read 376 times)

Tazate · **on:** Jul 23, 2018

The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?

A) Clarify discrepancies of assessment data with the client.
B) Validate client data with members of the health care team.
C) Document all data collected in the nursing history and physical examination.
D) Seek input from family members regarding the client's breathing at home.

Question 2

Which of the following examples of client data needs to be validated? Select all that apply.

A) A client has trouble reading an informed consent, but states he does not need glasses.
B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall.
C) A nurse examining a client with a respiratory infection documents fever and chills.
D) A client in a nursing home states that she is unable to eat the food being served.
E) A pregnant client is experiencing contractions that are two minutes apart.

Cnarkel · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: A
First, the nurse needs to validate the data with the client, who is the primary source. The nurse can validate data with the health care provider but consulting with the client is the best option. The client must give permission for family members to participate in the health history. Ultimately, the nurse documents all assessment data, both from the history and the physical exam.

Answer to Question 2

Ans:A, B

Because validation of all data is neither possible nor necessary, nurses need to decide which items need verification. For example, data need to be verified when there are discrepancies: A patient tells the nurse he is fine and has no concerns, but the nurse notes that he demonstrates tense body musculature and seems curt in his responses. When there is a discrepancy between what the person is saying and what the nurse is observing, validation is necessary to determine accuracy. Data also need verification when they lack objectivity.