A patient gives an unclear answer about the time that chest discomfort began. What should the nurse do next?
Correct answer: B. Ask a focused question to clarify the onset
- A. Record the answer without further questioning
- B. Ask a focused question to clarify the onset
- C. Ask the family to provide the exact time
- D. Document that the patient is an unreliable source
Explanation
The nurse should clarify incomplete or unclear information before documenting the assessment. This improves data accuracy and avoids labelling the patient as unreliable without adequate evidence.
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About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
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