A nurse is validating the data collected from an assessment of a client who has hypertension. Which of the following actions should the nurse take?

Compare the data with normal standards and ranges.

Use open-ended questions to clarify the data.

Repeat the assessment using a different method or source.

All of the above.

Answer and Explanation

The Correct Answer is D

Choice A:

Compare the data with normal standards and ranges. This is a valid action for the nurse to take, because it helps to identify any abnormal findings or deviations from the expected values. For example, the nurse can compare the client's blood pressure, pulse, and temperature with the normal ranges for adults.

Choice B:

Use open-ended questions to clarify the data. This is also a valid action for the nurse to take, because it allows the client to provide more information and elaborate on their responses. Open-ended questions are those that cannot be answered with a simple yes or no, such as "How do you feel about your condition?.”. or "What are your main concerns?.".

Choice C:

Repeat the assessment using a different method or source. This is another valid action for the nurse to take, because it helps to confirm the accuracy and reliability of the data. For example, the nurse can use a different device to measure the blood pressure, ask another health care professional to verify the findings, or check the client's medical records for previous data.

Choice D:

All of the above. This is the correct answer, because all of the actions listed above are appropriate ways for the nurse to validate the data collected from an assessment of a client who has hypertension. Validation is an important step in the assessment process, because it ensures that the data are complete, accurate, and consistent.

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Correct Answer is A

Explanation

Choice A reason:

The client will ambulate 50 feet with a walker by day 3. This is an example of a goal rather than an outcome because it is a specific action that the client intends to achieve within a certain time frame. It is also a process goal because it is a step or sub-goal towards a more significant and overarching goal, such as improving mobility or preventing complications. Process goals are more controllable and measurable than outcome goals.

Choice B reason:

The client will maintain fluid balance as evidenced by stable weight and urine output. This is an example of an outcome rather than a goal because it is the overarching result that the client intends to achieve. It is also an outcome goal because it enables the client to assess their present and intended performance results while developing an outline that guides the steps to realize it. Outcome goals are more general and less controllable than process goals.

Choice C reason:

The client will have improved gas exchange as indicated by oxygen saturation above 92%. This is an example of an outcome rather than a goal because it is the overarching result that the client intends to achieve. It is also an outcome goal because it enables the client to assess their present and intended performance results while developing an outline that guides the steps to realize it. Outcome goals are more general and less controllable than process goals.

Choice D reason:

The client will have normal bowel function. This is an example of an outcome rather than a goal because it is the overarching result that the client intends to achieve. It is also an outcome goal because it enables the client to assess their present and intended performance results while developing an outline that guides the steps to realize it. Outcome goals are more general and less controllable than process goals.

A. The client's level of fatigue and weakness. B. The client's cognitive and emotional status. C. The client's family history and genetic risk factors. D. The client's vision and hearing acuity. E. The client's mobility and coordination skills.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason:

The client's level of fatigue and weakness is an important data to collect because fatigue is one of the most common and disabling symptoms of MS, affecting about 80% of people with the condition. Fatigue can interfere with the client's daily activities, quality of life, and ability to cope with other symptoms. Weakness is also a common symptom of MS, caused by damage to the nerve fibers that control muscle movements. Weakness can affect the client's mobility, balance, and coordination.

Choice B reason:

The client's cognitive and emotional status is another important data to collect because MS can affect the brain and spinal cord, leading to cognitive impairment in about 50% of people with MS. Cognitive impairment can affect the client's memory, attention, concentration, problem-solving, and decision-making skills. MS can also cause emotional changes, such as depression, anxiety, mood swings, irritability, and euphoria. Emotional changes can affect the client's coping skills, social relationships, and self-esteem.

Choice C reason:

The client's family history and genetic risk factors is not an important data to collect because MS is not a hereditary disease. Although genetic factors may play a role in increasing the susceptibility to MS, they are not sufficient to cause the disease by themselves. MS is thought to be caused by a combination of genetic and environmental factors that trigger an autoimmune response in the central nervous system. Therefore, knowing the client's family history and genetic risk factors will not help in diagnosing or managing MS.

Choice D reason:

The client's vision and hearing acuity is an important data to collect because MS can affect the optic nerve and cause visual disturbances, such as blurred vision, double vision, loss of color vision, pain in the eye, or temporary blindness. Visual disturbances are often the first symptom of MS and can recur or worsen over time. MS can also affect the auditory nerve and cause hearing problems, such as hearing loss, tinnitus, or vertigo. Hearing problems are less common than visual problems in MS but can still affect the client's communication and quality of life.

Choice E reason:

The client's mobility and coordination skills is an important data to collect because MS can damage the nerve fibers that control muscle movements and cause spasticity, tremors, ataxia, dysmetria, or dysdiadochokinesia. These symptoms can affect the client's mobility and coordination skills and increase the risk of falls, injuries, or disability. Assessing the client's mobility and coordination skills can help in planning interventions to improve function, safety, and independence.

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A nurse is validating the data collected from an assessment of a client who has hypertension. Which of the following actions should the nurse take?

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