Using critical thinking, the nurse assesses that a patient is not a reliable historian. How should the nurse proceed?
1. Stop the assessment because all data is invalid.
2. Document that the patient is not answering questions truthfully.
3. Ask different questions to assess the same information.
4. Document the information just as the patient reports it.
3
Rationale 1: There are many parts of assessment that do not depend on the patient being an accurate historian.
Rationale 2: Being an unreliable historian does not mean that the patient is not truthful. In some cases it indicates that the patient has memory or hearing issues.
Rationale 3: The nurse can assess information in a variety of ways. Asking different questions to elicit information is a valid technique.
Rationale 4: The nurse should not taint the data set by recording obviously inaccurate data. Further attempts to verify data should be taken.
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ANS:
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