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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Episodic acute stress: This term is not commonly used in clinical practice and does not accurately describe the condition associated with recurring flashbacks of a past traumatic event.
B. Irritable bowel syndrome (IBS): IBS is a gastrointestinal disorder and is not related to the psychological symptoms described, such as flashbacks of traumatic events.
C. Acute stress disorder (ASD): ASD occurs within the first month after a traumatic event and involves symptoms like flashbacks, but since the traumatic event occurred a year ago, it is more consistent with PTSD.
D. Posttraumatic stress disorder (PTSD): PTSD is characterized by persistent symptoms such as flashbacks, intrusive memories, and severe anxiety that occur long after the traumatic event, fitting the client's reported symptoms.
Correct Answer is C
Explanation
A. Acute Pain: This represents the diagnostic label in the nursing diagnosis but does not include specific symptoms or evidence related to the client's condition.
B. Natural swelling: This is not relevant to the symptoms described in the scenario and does not represent the specific signs of the client's condition.
C. Guarding and restricted movement: This describes the specific observable signs and symptoms reported by the patient, which are part of the "Signs and Symptoms" component (S) in the PES format.
D. Related to incisional trauma: This part of the diagnosis describes the cause or contributing factor of the pain, which is the "Etiology" component, not the "Signs and Symptoms."
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