The nurse is admitting a client transferred from the emergency room to the cardiac unit.
Which is the primary source of data?
The medical records.
The physician.
The client.
The significant others.
The Correct Answer is C
Choice A rationale
Medical records are considered a secondary source of data because they contain information documented by other healthcare professionals rather than direct, real-time input from the client. While records provide essential historical context, such as past diagnoses and lab results within normal ranges like a serum creatinine of 0.6 to 1.2 mg/dL, they may not reflect the client's current status. Primary data must come directly from the source being assessed during the current admission process.
Choice B rationale
The physician is a secondary source of information because their data is based on their own physical examinations and interpretations of the client's condition. While the physician's input is vital for the plan of care, it is not the original source of the client's subjective experiences. For a nurse conducting an admission assessment, relying solely on another professional's report can lead to the omission of critical details that only the client can provide.
Choice C rationale
The client is the primary source of data as they provide subjective information regarding their symptoms, feelings, and personal history. In nursing assessments, the most accurate and direct information about a client's condition comes from the person experiencing it. This direct communication allows the nurse to gather specific details about pain levels or changes in function that cannot be replicated by secondary sources, making it the gold standard for initiating a plan of care.
Choice D rationale
Significant others are categorized as secondary sources of data because they provide information from an external perspective. They are valuable when the client is unable to communicate due to unconsciousness or cognitive impairment, but their reports remain secondary to the client's own input. While family members can provide context about the client's baseline at home, the nurse must prioritize the client's direct reports whenever the client is alert and oriented to ensure accuracy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,A,D,C
Explanation
The correct sequence for an abdominal assessment is inspection, auscultation, percussion, and then palpation. Inspection is done first to observe the surface for abnormalities. Auscultation follows immediately because touching or pressing on the abdomen during percussion or palpation can artificially increase bowel motility and change the character of bowel sounds. By auscultating early, the nurse hears the most natural state of the gut. Percussion and palpation are saved for last to prevent discomfort.
Correct Answer is D
Explanation
Choice A rationale
While the presence of drainage from a lesion can be a clinical sign of a localized infection or the body trying to clear debris, it is not a specific laboratory or systemic indicator of the inflammatory process. Drainage is a physical manifestation of tissue breakdown and cellular response. In chronic wounds, drainage may persist for various reasons, including poor circulation, making it less specific as an acute inflammatory marker compared to serum proteins.
Choice B rationale
The platelet count in this patient is 375,000/uL, which is slightly above the normal range of 150,000 to 350,000/uL. Although platelets can act as acute phase reactants and increase slightly during stress or inflammation, this elevation is mild and non-specific. It does not provide a definitive measure of the intensity or presence of an acute inflammatory cascade as reliably as specific biochemical proteins like C-reactive protein or the white blood cell count.
Choice C rationale
Pain is a subjective experience and one of the cardinal signs of inflammation, which also include heat, redness, and swelling. However, pain perception is highly individualized and can be influenced by chronic neuropathy, especially in patients with chronic wounds or diabetes. Therefore, a subjective report of pain is not a quantifiable laboratory finding and cannot be used to objectively measure or monitor the physiological severity of an acute inflammatory response in a clinical setting.
Choice D rationale
C-reactive protein is an acute-phase reactant synthesized by the liver in response to cytokines like interleukin-6 during the early stages of inflammation. The normal range is usually less than 10 mg/dL. A value of 15 mg/dL directly reflects systemic inflammatory activity. Unlike white blood cells, which can be elevated by various stressors, C-reactive protein rises and falls rapidly in direct correlation with the inflammatory stimulus, making it the most specific indicator provided for this client.
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