Which of the following examples of client data needs to be validated? Select all that apply
A) A client has trouble reading an informed consent, but states he does not need glasses.
B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall.
C) A nurse examining a client with a respiratory infection documents fever and chills.
D) A client in a nursing home states that she is unable to eat the food being served.
E) A pregnant client is experiencing contractions that are two minutes apart.
Ans:A, B
Because validation of all data is neither possible nor necessary, nurses need to decide which items need verification. For example, data need to be verified when there are discrepancies: A patient tells the nurse he is fine and has no concerns, but the nurse notes that he demonstrates tense body musculature and seems curt in his responses. When there is a discrepancy between what the person is saying and what the nurse is observing, validation is necessary to determine accuracy. Data also need verification when they lack objectivity.
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