The nurse is documenting the following information that has been ...

[biggirl4568]

The nurse is documenting the following information that has been collected during the health history. Rank the following information in the order that it should be documented.
 
  Select the correct choice from the list.
  Response 1. Diagnosed with renal insufficiency in 1997.
  Response 2. Malignant melanoma (stage I) removed from one site in 1992.
  Response 3. Coronary artery bypass graft in July 2005.
  Response 4. Diagnosed with hypertension in 2000.

Question 2

The nurse is gathering client data from secondary sources. Which sources would the nurse utilize to collect this data?
 
  Select all that apply.
  1. The client's past medical records.
  2. The client.
  3. The history and physical.
  4. The client's physical therapist.
  5. The client's spouse.

[Dunkey]

Answer to Question 1

Correct Answer: 3, 4, 1, 2

When recording data, the information should be written in descending order from present to past. The first thing that should be documented is the coronary artery bypass graft in July 2005. The second item is that the client was diagnosed with hypertension in 2000. The third item is the client's diagnosis of renal insufficiency in 1997. The fourth item is the client's malignant melanoma that was removed from one site in 1992

Answer to Question 2

Correct Answer: 1, 3, 4, 5

Secondary sources are used to augment and validate previously obtained data. The following are examples of secondary sources: medical records, the client's history and physical, a physical therapist who has worked with the client, other healthcare personnel who have cared for the client, and the client's spouse. The client is considered the primary source of information.

[biggirl4568]

Excellent

[ryhom]

TYSM