A nurse is assisting in the care of a client who presents to the emergency department.

Exhibits

A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?

Valid and reliable health information sources should provide references or citations to support the information they present. This demonstrates that the information is based on evidence and has been reviewed by experts in the field. It allows readers to verify the accuracy and reliability of the information by referring to the cited sources.

The author's name listed without credentials does not provide information about the author's expertise or qualifications. It is important to assess the author's credentials and expertise to determine their credibility.

The website URL being listed as .com does not provide information about the accuracy or reliability of the content. Different types of websites, such as .org or .gov, can also contain credible health information.

The website being last updated 3 years ago raises concerns about the currency and relevance of the information. Health information can quickly evolve, and it is important to access up-to-date resources.

A.While it's important to document visitors and support persons, this information may not be considered crucial for the change-of-shift report unless it directly impacts the client's care or well-being.

B. The client received the prescribed antibiotic every 8 hours: This is important information, but it is typically documented in the medication administration record (MAR) and does not need to be included in the verbal report unless there were issues or changes related to the medication.

C. The client reports pain is reduced when positioned on his side: This is significant information as it informs the incoming nurse about the client's preferred position for pain management. It helps guide the nurse in providing comfort measures and appropriate positioning for the client. The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.

D. The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.