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 C

Explanation

A. Wheezes: Wheezes are high-pitched sounds usually associated with airway constriction, such as in asthma, not specifically lobar pneumonia.

B. Rhonchi: Rhonchi are low-pitched, snoring sounds associated with secretions in the airways and may be present in pneumonia but are not the most characteristic finding.

C. Coarse crackles (rales): Coarse crackles or rales are bubbling, crackling sounds heard when air moves through fluid in the airways, which is typical in pneumonia due to the presence of alveolar fluid.

D. No sound: Absence of sound is not expected in pneumonia; adventitious sounds like crackles are usually present.

A. Wait until the end of the physical assessment to reassess the radial pulse. B. Reassess the client's pedal pulse on the other foot. C. Assess the client's 51 and 52 sounds for regularity. D. Assess the client's apical pulse for a full minute.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A senior patient is being admitted due to lobar pneumonia to the med-surgical floor. When auscultating, the nurse would expect to listen to which of the following adventitious breath sounds?

Correct Answer is C

Explanation

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

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