A patient states, "I'm so worried that I might have cancer." The nurse responds, "It is time for you to eat breakfast." The nurse's response is an example of.
judgmental response.
using clichés.
changing the subject.
giving false reassurance.
The Correct Answer is C
A. Judgmental response.
This isn’t necessarily judgmental, as it doesn't express an opinion about the patient’s feelings or concern.
B. Using clichés.
Clichés are general or overused phrases meant to provide comfort but are not present here.
C. Changing the subject.
Changing the subject dismisses the patient's concern without acknowledging it, which is evident here as the nurse diverts to breakfast without addressing the worry.
D. Giving false reassurance.
False reassurance involves saying something unrealistic to make the patient feel better, which isn't directly done here.
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Correct Answer is D
Explanation
A. “Taking fluids poorly, but more than yesterday."
This assessment is vague (“taking fluids poorly”), lacks measurable details, and does not meet the clarity standard required in documentation.
B. "Apparently comfortable all night. Offers no complaints of pain."
“Apparently comfortable” is an assumption rather than an observable, objective statement, which could be legally questionable.
C. "Patient says she is still slightly nauseated, would like to try some toast and tea."
While this is clear, “slightly nauseated” could be more specific, and this does not objectively quantify the patient’s condition.
D. "4 cm reddened area over sacrum. Skin intact, warm, and dry."
This statement is concise, uses precise measurements, and includes objective data, meeting legal documentation guidelines.
Correct Answer is C
Explanation
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.