A clinic nurse is documenting in a patient medical record about the pain that brought the patient to seek medical attention. The best description is:
"Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch."
"Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch."
"Periumbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids."
"Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse."
The Correct Answer is C
A. "Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch."
This documentation provides details but lacks specific information on the pain’s nature and duration.
B. "Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch."
This statement includes diet details but lacks a pain intensity rating and specific location.
C. "Periumbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids." This statement is the most thorough, including location, nature, intensity, duration, and lack of relief from interventions.
D. "Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse."
This is incomplete, as it lacks a specific location and description of the pain’s onset.
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Correct Answer is B
Explanation
A. Write down remarks on a clipboard to facilitate later topics of conversation.
Writing down remarks could distract from active listening and might make the patient feel as though the nurse isn’t fully engaged in the conversation.
B. Make a conscious effort to block out other sounds in the immediate environment.
Active listening requires focusing on the speaker by minimizing distractions, allowing the nurse to be fully attentive to the patient.
C. Maintain eye contact by staring at the patient.
Active listening involves natural eye contact, not staring, as staring can be intimidating and may cause discomfort for the patient.
D. Prompt the patient when the patient stops talking for a moment.
Giving the patient time to think and process without prompting respects their pace and encourages them to share more when ready.
Correct Answer is B
Explanation
A. Saving the extra time it would take to mail the information.
The purpose of asking the patient to repeat information is not about saving time but to ensure accurate understanding.
B. Verifying that the patient understands the information.
Asking the patient to repeat the information confirms that they understood it correctly, which is essential in promoting effective communication and preventing misunderstandings.
C. Acting in a cautious way to avoid charges of negligence. While caution is involved, the primary purpose is to ensure understanding rather than legal protection.
D. Testing the patient's intelligence and memory.
This is not a test of intelligence or memory but rather a verification of understanding.