The nurse working in the ER is admitting a toddler to the orthopedic unit. The parents and grandparents are at bedside. What should the nurse use as the best source of data for this client?
Grandparents
Admitting provider
Parents
Medical record
The Correct Answer is C
A. Grandparents: While grandparents can provide valuable information, parents are typically the primary source of information about a child’s medical history, current symptoms, and behavioral changes.
B. Admitting provider: The admitting provider's role is to assess and diagnose the client. While they provide essential clinical information, they are not the primary source for personal and historical data about the client.
C. Parents: Parents are the most reliable source of information regarding the toddler's medical history, current condition, and any changes in behavior or health. They are most familiar with the child’s day-to-day health and medical background.
D. Medical record: Although the medical record contains important information, it may not have the most recent updates or contextual details that parents can provide. It is important to corroborate the information in the medical record with input from the parents.
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Related Questions
Correct Answer is C
Explanation
A. Acute pain manifested by client's report: While this diagnosis reflects the client's report of pain, it does not address the underlying cause or etiology of the pain, which is important for forming an effective care plan.
B. Acute pain related to psychosomatic condition: This diagnosis implies a specific psychosomatic origin for the pain. Since the etiology is unknown, attributing it to a psychosomatic condition may not be accurate.
C. Acute pain related to unknown etiology: This diagnosis is the most appropriate because it acknowledges the presence of acute pain and explicitly notes that the cause is unknown, which aligns with the information provided.
D. Acute pain related to unknown factors: This diagnosis is similar to C, but "unknown factors" is less precise than "unknown etiology." The term "etiology" more accurately describes the underlying cause.
Correct Answer is D
Explanation
A. Involves respiratory therapy for altered breathing from severe anxiety levels: This behavior demonstrates collaboration with other healthcare professionals but does not directly relate to a team approach for managing mobility issues.
B. Delegates assessment of lung sounds to nursing assistive personnel: Delegation of tasks such as assessing lung sounds is a nursing responsibility but does not involve the broader team approach necessary for comprehensive care.
C. Becomes solely responsible for modifying activities of daily living: Handling all aspects of a patient's care individually does not reflect a team approach, which involves collaborating with various specialists.
D. Consults physical therapy for strengthening exercises in the extremities: This behavior exemplifies a team approach by involving physical therapy specialists to address mobility issues. It reflects collaboration with other disciplines to provide comprehensive care.
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