The nurse is reviewing assessment findings on a patient admitted with an extremely slow heart rate. The patient complains of dizziness, shortness of breath, chest pain, and fainting spells
Vital signs are blood pressure of 98/60 mm Hg and pulse of 52 beats/minute. Oxygen saturation is 88%. Which action should the nurse perform next?
a.
Exclude all subjective data in favor of objective data.
b.
Focus on data gathered during the physical assessment.
c.
Evaluate the data looking for patterns and related data.
d.
Dismiss family members input as "hearsay."
ANS: C
After collecting and reviewing all of the assessment data, the nurse looks for patterns and related data to support specific nursing diagnoses. This process is referred to as clustering data. Clustering involves organizing patient assessment data into groupings with similar underlying causes. All patient information should be considered as potentially contributing to the identification of diagnostic labels. This information includes subjective and objective data collected through physical assessment of the patient, interview of the patient and family members, and laboratory and diagnostic test results, including x-rays, physicians' orders, and documentation from health care providers. Verifying specific nursing diagnoses for a particular patient or situation follows accurate analysis and clustering of data.
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