While conducting a comprehensive assessment the client states ...

[jjjetplane]

While conducting a comprehensive assessment the client states that she is experiencing a headache due to high blood pressure. How should the nurse corroborate this information?
 
  1. Checking the client's temperature
  2. Recording the client's pain score
  3. Asking the spouse for confirmation
  4. Measuring the blood pressure

Question 2

Prior to conducting a partial assessment with a 72-year-old client the nurse notes that the client intake and output are balanced even though a previous note indicates that the client is dehydrated based upon dry skin.
 
  What should the nurse conclude about this information?
 
  1. The client is dehydrated.
  2. The accuracy of the earlier assessment is in question.
  3. The client's condition has deteriorated.
  4. The client has increased fluid intake.

[cclemon1]

Answer to Question 1

Answer: 4

1. The client's temperature will not validate high blood pressure.
2. The nurse validates using objective data. Pain score is a subjective symptom.
3. The spouse cannot corroborate the client's blood pressure.
4. The nurse should measure the client's blood pressure to validate the client's subjective information.

Answer to Question 2

Answer: 2

1. If the client's intake and output are appropriate, it is not likely that the client is dehydrated.
2. The accuracy should be questioned because the elderly experience dry skin with poor turgor as a normal part of aging.
3. The client's output is appropriate so it is not likely that the client has deteriorated.
4. The evidence shows that the client is drinking the appropriate amount of fluid.

[jjjetplane]

Excellent

[ricroger]

TYSM