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 D

Explanation

A. Wheezes:

Wheezes are high-pitched, musical sounds that occur during inspiration or expiration and are often associated with narrowed airways, such as in conditions like asthma or chronic obstructive pulmonary disease (COPD).

B. Stridor:

Stridor is a high-pitched, crowing sound that is typically heard during inspiration and can be associated with upper airway obstruction, such as in croup or epiglottitis.

C. Rhonchi:

Rhonchi are low-pitched, snoring or rattling sounds that can occur during inspiration or expiration. They are often associated with the presence of mucus or other airway obstruction and can be heard in conditions like bronchitis or pneumonia.

D. Crackles:

Crackles are bubbling, popping sounds heard during inspiration or expiration. They can be further classified as fine or coarse. Fine crackles are often associated with conditions like pulmonary fibrosis, while coarse crackles can be heard in conditions like congestive heart failure or pneumonia.

A. Regular deep respirations interspersed with periods of apnea B. A pattern of crescendo-decrescendo respirations followed by a period of apnea C. Patient breathing less than 10 breaths per minute D. Patient breathing shallow and more than 24 breaths per minute

Correct Answer is B

Explanation

A. Regular deep respirations interspersed with periods of apnea:

This describes periodic breathing, which is different from Cheyne-Stokes respirations. Periodic breathing consists of regular cycles of deep respirations followed by periods of apnea.

B. A pattern of crescendo-decrescendo respirations followed by a period of apnea

Cheyne-Stokes respirations are characterized by a pattern of crescendo-decrescendo respirations, meaning that the depth and rate of breathing gradually increase and then decrease. This is followed by a period of apnea, during which there is a temporary cessation of breathing. The cycle then repeats.

C. Patient breathing less than 10 breaths per minute:

This describes bradypnea, which is an abnormally slow respiratory rate. Cheyne-Stokes respirations involve rhythmic, cyclical changes in respiratory rate and depth.

D. Patient breathing shallow and more than 24 breaths per minute:

This describes tachypnea, which is an abnormally fast respiratory rate. Cheyne-Stokes respirations are characterized by a distinct pattern of alternating crescendo-decrescendo respirations followed by apnea.

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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?

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Explanation

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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?