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Answer :
To validate the client's health status, the nurse needs to assess the client's claim of a hard, raised, red lesion on his right hand, the reported infected toe, and the blood pressure readings of 124/70 and 118/68. This involves questioning the client about the symptoms and inspecting the affected areas.
The nurse needs to validate subjective statements from the client rather than objective data that are factually recorded in the medical record or can be measured/observed directly. Among the options provided, the nurse would need to validate:
- The client has a hard, raised, red lesion on his right hand. This involves direct observation to make sure the chart description matches what the nurse see.
- The client reported an infected toe. The nurse should validate this complaint from the client by questioning the client about the symptoms and inspecting the toe.
- The client's blood pressure is 124/70. It was 118/68 yesterday. Although blood pressure are typically measured and recorded by medical devices, the nurse should double check if there's a significant change to this effect.
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