The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?
A) Clarify discrepancies of assessment data with the client.
B) Validate client data with members of the health care team.
C) Document all data collected in the nursing history and physical examination.
D) Seek input from family members regarding the client's breathing at home.
Ans: A
First, the nurse needs to validate the data with the client, who is the primary source. The nurse can validate data with the health care provider but consulting with the client is the best option. The client must give permission for family members to participate in the health history. Ultimately, the nurse documents all assessment data, both from the history and the physical exam.
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