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 D
Explanation
A. Actions of the nurse are appropriate since his neighbor is his confidante, and the neighbor has assured him the information provided will not be shared. Confidentiality must be maintained regardless of assurances from others; sharing patient information outside a professional context is a violation of privacy.
B. Nurse has not violated the confidentiality of the patient because the patient is terminal; sharing this information will not harm the patient. Confidentiality must be maintained regardless of the patient's condition. Privacy and confidentiality are ethical requirements for all patients, terminal or otherwise.
C. Nurse is actively promoting nursing as a profession, and it is important to share information that might encourage others to pursue a nursing career. While promoting the profession is valuable, using a patient’s personal information is inappropriate and unprofessional. There are ethical ways to promote nursing without breaching confidentiality.
D. Nurse has violated the confidentiality of the patient by discussing personal information about the patient with his neighbor. Sharing patient information with someone who is not involved in the patient’s care violates HIPAA and confidentiality standards. This action is unprofessional and unethical.
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.