When the nurse is assessing a patient, the best action by the nurse is to
a. focus on assessment data collected with the five senses.
b. not rely on information from friends, who may be wrong.
c. use both primary and secondary sources of information.
d. use secondary sources to determine assessment priorities.
C
To collect a complete database, the nurse needs to use both primary and secondary sources of information.
Physical assessment data are collected through the nurse's five senses, but limiting data to this severely restricts the database.
Significant others, including friends and family, are important secondary sources of information about the patient.
Neither primary nor secondary sources of data should be considered solely to guide further assessments. They are both valuable sources of complete information about the patient.
You might also like to view...
Lorena, an RN, is flying from Los Angeles to New York. The flight attendant requests the help of a nurse or physician if one is on board. Lorena approaches the flight attendant and asks if she can assist
Lorena is protected by the Good Samaritan Act because the act states that a licensed health-care provider can: A) Administer care any time B) Provide care that any other prudent individual with the same education would provide C) Provide the same care as a paramedic D) Provide care outside the scope of her practice as long as she knows how to perform the required procedure
A 17-year-old girl with spina bifida has erythema and itching around her mouth after blowing up a balloon. This is likely due to which of the following?
A) A developing cold sore B) A food allergy C) A latex allergy D) Facial eczema
When preparing a woman for an amniocentesis, the nurse would instruct her to do which of the following?
A) Shower with an antiseptic scrub. B) Swallow the pre-procedure sedative. C) Empty her bladder. D) Lie on her left side.
The nurse is instructing a patient with benign prostatic hyperplasia about techniques to reduce urinary retention. What should these instructions include?
A. Avoid alcoholic beverages. B. Over-the-counter cold remedies are permitted with other medications. C. Urinate until all of the urine is drained from the bladder. D. Encourage ingesting large amounts of fluids at one time.