A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse use as a primary source of accurate data about the client?
Family information
Client concerns
Progress note
Medical history
The Correct Answer is B
A. Family information is considered a secondary source because it provides supportive data but may not fully reflect the client’s own experience or symptoms.
B. Client concerns are the primary source of accurate data because the client is the best authority on their own health, symptoms, feelings, and experiences.
C. Progress notes are secondary sources that document observations and interventions by healthcare providers, but they are not firsthand information from the client.
D. Medical history provides valuable background but is also a secondary source, as it is typically gathered from records or other providers rather than directly from the client at the time of admission.
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Related Questions
Correct Answer is D
Explanation
A. A black tag indicates a client who is deceased or expected to die due to catastrophic injuries. These clients receive comfort measures only, as survival is unlikely even with treatment.
B. A yellow tag is for clients with serious but not life-threatening injuries. Treatment can be delayed without immediate risk of death.
C. A green tag indicates minor injuries (often called “walking wounded”). These clients are stable and can wait for care until more urgent cases are treated.
D. A red tag identifies clients who have life-threatening but potentially survivable injuries that require immediate intervention. These clients are the highest priority during triage, as prompt treatment can significantly improve survival outcomes.
Correct Answer is D
Explanation
A. A durable power of attorney for health care (DPOA-HC) allows a designated person to make health decisions only when the client cannot, but they cannot override or cancel the client’s living will. The living will represents the client’s direct written wishes, which must be followed.
B. The Patient Self-Determination Act requires healthcare facilities to inform clients of their rights to make decisions regarding medical care, including advance directives, but it does not grant families the authority to modify an existing living will once the client is incapacitated.
C. The case manager facilitates coordination of care and client services but has no legal authority to alter or amend a client’s advance directive or living will.
D. This is the correct and legally accurate statement. A living will is a written legal document that outlines a client’s preferences for lifesaving or life-sustaining treatments (such as CPR, mechanical ventilation, or tube feeding) if they become incapacitated. Once the client is unconscious or unable to communicate, healthcare providers must honor the instructions in the living will as it reflects the client’s autonomous decisions.
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