The nurse is assessing an older adult client at a hospice unit. The client cannot speak or communicate, but the client's daughter is there and answers all the questions as best as she can. What type of data source is the daughter?

Subjective

Tertiary

Secondary

Primary

Answer and Explanation

The Correct Answer is C

A. Subjective: Subjective data refers to information reported by the patient directly, which is not applicable in this case since the client cannot communicate.

B. Tertiary: This term is not commonly used in the context of data sources in health assessments.

C. Secondary: Secondary data is information provided by someone other than the patient, such as a family member or caregiver, which is applicable here since the daughter is providing the information.

D. Primary: Primary data is directly obtained from the patient, not from a secondary source like the daughter.

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

Explanation

A. Wait until the end of the physical assessment to reassess the radial pulse: If the radial pulse is irregular, it is important to reassess it to confirm irregularity. However, waiting until the end of the assessment is not recommended; it is better to reassess promptly.

B. Reassess the client's pedal pulse on the other foot: This is not related to assessing the regularity of the radial pulse.

C. Assess the client's 51 and 52 sounds for regularity: These terms are not standard in assessing pulse regularity; the focus should be on the apical pulse for an irregular radial pulse.

D. Assess the client's apical pulse for a full minute: The apical pulse should be assessed for a full minute to accurately determine the heart rate and rhythm, especially if the radial pulse is irregular.

A. Moist nasal mucosa B. Cerumen in the ear C. Enlarged lymph node in the neck D. Acne lesions on the face and upper chest

Correct Answer is C

Explanation

A. Moist nasal mucosa: This is generally a normal finding and does not usually require immediate follow-up unless there are other symptoms suggesting infection or other issues.

B. Cerumen in the ear: While cerumen can impact hearing, it is typically not an urgent issue and can be managed with appropriate ear care.

C. Enlarged lymph node in the neck: Enlarged lymph nodes can indicate an underlying infection or malignancy, especially if persistent or accompanied by other symptoms, thus requiring immediate follow-up.

D. Acne lesions on the face and upper chest: Acne is common and usually not an urgent concern unless it is severe or causing significant distress.

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The nurse is assessing an older adult client at a hospice unit. The client cannot speak or communicate, but the client's daughter is there and answers all the questions as best as she can. What type of data source is the daughter?

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Naxlex Comprehensive Predictor Exams

During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

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

Explanation

When the nurse collects objective data, which finding requires immediate follow-up?

Correct Answer is C

Explanation

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