A nurse is assisting with the admission of an alert and oriented client to the orthopedic surgical unit.

Which of the following sources of information should the nurse rely on for accurate information about the client?

The client

Progress note

Medical history

Family information

Answer and Explanation

The Correct Answer is A

A. The client:

The client is the most reliable source of information about their own health. Direct communication with the client allows the nurse to gather details about their symptoms, medical history, current health status, and any other relevant information. This is crucial for accurate assessment and care planning.

B. Progress note:

Progress notes are documentation by healthcare providers that summarize the client's clinical status, interventions, and responses to care. While progress notes can provide valuable information, they are not always as up-to-date as direct communication with the client.

C. Medical history:

The medical history contains information about the client's past health conditions, treatments, and surgeries. While important, medical history may not capture the most recent or current information, especially if there have been recent changes in the client's health.

D. Family information:

Family information can provide additional context, support, and insights into the client's health. However, it may not always be as accurate or comprehensive as the information obtained directly from the client. Family members may not be aware of recent changes or may have different perspectives on the client's health.

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Correct Answer is A

Explanation

A. Carotid

The nurse should avoid assessing the carotid pulses bilaterally at the same time. The carotid arteries are major blood vessels supplying the head and neck with oxygenated blood. Simultaneously assessing both carotid pulses could potentially compromise blood flow to the brain, leading to a decrease in cerebral perfusion. This is particularly important in individuals with a history of cerebrovascular disease or other conditions affecting blood flow to the brain.

B. Brachial:

Assessing the brachial pulses bilaterally at the same time is generally acceptable. The brachial pulses are located in the upper arms.

C. Popliteal:

Assessing the popliteal pulses bilaterally at the same time is generally acceptable. The popliteal pulses are located behind the knee.

D. Femoral:

Assessing the femoral pulses bilaterally at the same time is generally acceptable. The femoral pulses are located in the groin area.

A. Edema B. Heart Rate C. Chills D. Pallor

Correct Answer is C

Explanation

A. Edema:

Edema refers to the presence of swelling caused by an accumulation of fluid. While the nurse can observe and measure edema, the sensation of swelling itself is subjective and based on the client's perception.

B. Heart Rate:

Heart rate is an objective measure of the number of heartbeats per minute. It can be measured and observed by the healthcare provider, making it an objective data point.

C. Chills

Subjective data refers to information that is based on the client's personal experiences, perceptions, and feelings. Chills, which describe a feeling of coldness often associated with shivering, are a subjective symptom that the client experiences.

D. Pallor:

Pallor refers to an unusually pale or white skin color. While the nurse can observe and assess the color of the skin, the client's perception of pallor is subjective.

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A nurse is assisting with the admission of an alert and oriented client to the orthopedic surgical unit. Which of the following sources of information should the nurse rely on for accurate information about the client?

Nursing Test Bank

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A nurse is assisting with the admission of an alert and oriented client to the orthopedic surgical unit.

Which of the following sources of information should the nurse rely on for accurate information about the client?