Question

A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she conducts rounds on the patient? (Select all that apply.)

The nurse asks the patient to rate his pain on a scale of 0 to 10.
The nurse asks the patient what caused his fall.
The nurse asks the patient if he has had pain in his back in the past.
The nurse assesses the patient's lower-limb strength.
The nurse asks the patient what pain medication is most effective in managing his pain.

Answer 1

To validate the previous nurse's assessment findings, the nurse can ask the patient to rate his pain, inquire about the cause of the fall, and assess the patient's lower-limb strength.

Step-by-step explanation:

In order to validate the previous nurse's assessment findings when conducting rounds on the patient, the nurse beginning a shift can do the following:

1. Ask the patient to rate his pain on a scale of 0 to 10: This will help assess the severity of the pain and compare it to the previous nurse's assessment.
2. Ask the patient what caused his fall: This will provide additional information about the event that led to the current condition and help validate the timeline of events.
3. Assess the patient's lower-limb strength: This will help determine if there are any weaknesses or difficulties in movement, which aligns with the previous nurse's assessment of the patient's difficulty turning in bed and slow transfer to a chair.

By using these methods, the nurse can gather information that aligns with the previous nurse's assessment, providing validation and ensuring accurate care.