A patient is confused and cannot provide a reliable health history. Which action is most appropriate?
Correct answer: B. Obtain relevant information from a reliable family member
- A. Document that no history can be obtained
- B. Obtain relevant information from a reliable family member
- C. Wait until discharge to collect the patient's history
- D. Assume that the previous admission record is complete
Explanation
A reliable family member or caregiver can provide secondary information when the patient cannot respond accurately. The nurse should identify the source and confirm information from available records when possible.
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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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