Question

The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring.

During the interview, the client denies problems with breathing. What action should the nurse take next?
A) Clarify discrepancies of assessment data with the client.
B) Validate client data with members of the health care team.
C) Document all data collected in the nursing history and physical examination.
D) Seek input from family members regarding the client's breathing at home.

Answer 1

The nurse should clarify discrepancies of assessment data with the client next, as the client denies problems with breathing despite exhibiting physical signs of respiratory distress.

Step-by-step explanation:

The nurse should Clarify discrepancies of assessment data with the client next.

Although the client denies problems with breathing, the nurse has observed physical signs that indicate respiratory distress, such as a respiratory rate of 30, audible wheezing, and nasal flaring. By clarifying discrepancies of assessment data with the client, the nurse can ensure accurate and complete information is obtained, which is crucial for providing appropriate care.

It is important for the nurse to communicate openly and non-judgmentally with the client, allowing them to express any concerns or symptoms they may have overlooked or misunderstood.