When performing a thorough physical assessment on a patient, the licensed practical nurse (LPN) begins collecting primary data. An example of primary data is that
The patient's daughter appears anxious about the patient's hospitalization.
The patient reports a history of chronic obstructive pulmonary disease.
The patient's spouse reports the patient has difficulty sleeping.
The patient's caregiver complains of feeling overwhelmed.
The Correct Answer is B
A: The daughter's anxiety is secondary information and not directly related to the patient's health status.
B: The patient's self-reported medical history is primary data as it comes directly from the patient and provides essential information for the assessment.
C: The spouse's report of the patient's difficulty sleeping is secondary information and not directly observed or reported by the patient.
D: The caregiver's complaint is secondary information and does not provide direct insight into the patient's health status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: To accurately assess for orthostatic hypotension, the initial blood pressure should be measured while the client is supine. This establishes a baseline for comparing subsequent measurements.
B: Placing the client in a sitting position is a subsequent step in the sequence to monitor changes but is not the first action.
C: Determining the client's blood pressure changes after each position is essential but follows the initial supine measurement.
D: Assisting the client into a standing position is also part of the assessment process for orthostatic hypotension but should occur after recording the supine and sitting blood pressures.
Correct Answer is C
Explanation
A: This is not suitable for assessing circulation issues specifically in the lower extremities as it is located on the upper body.
B: This is not suitable for assessing circulation issues specifically in the lower extremities as it is located on the upper body.
C: Palpating the posterior tibialis pulse is a logical next step for checking lower extremity circulation, particularly when dorsalis pedis is not palpable, helping localize the evaluation of blood flow in the foot and ankle.
D: The femoral pulse is useful for broader leg circulation issues. However, it is less targeted than posterior tibialis for checking blood flow in the lower extremities.
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