A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says to the nurse, "I don't want to have you draw any more blood for those useless tests." When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:
"Blood not drawn because tests are no longer desired by patient."
"Refuses to have blood drawn; says tests are 'useless. Doctor notified."
"Doctor notified of failure to draw ordered blood work."
"Refuses to have blood drawn. Doctor notified."
The Correct Answer is B
A. "Blood not drawn because tests are no longer desired by patient."
This statement is vague and lacks specific details regarding the patient's exact refusal and the communication with the doctor.
B. "Refuses to have blood drawn; says tests are 'useless.' Doctor notified."
This response documents the patient's refusal with their exact words ("useless") and also notes that the doctor has been informed, which is essential for clear, complete documentation.
C. "Doctor notified of failure to draw ordered blood work."
This documentation lacks the reason for the blood draw failure (patient refusal) and omits the patient’s specific wording.
D. "Refuses to have blood drawn. Doctor notified."
Although this documents the refusal and the doctor’s notification, it omits the patient’s exact words, which can provide additional context for the healthcare team.
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Correct Answer is C
Explanation
A. Speaking slowly and clearly in the patient's native language. While speaking clearly in the patient’s native language is helpful, it does not verify understanding. Feedback from the patient is necessary to confirm comprehension.
B. Asking the family members whether the patient understands. Relying on family members may not be accurate, as they may not fully understand the patient's level of comprehension.
C. Obtaining feedback from the patient that indicates accurate comprehension. Having the patient repeat the information back or summarize it in their own words ensures they have understood the communication.
D. Checking for signs of hearing loss or aphasia before communicating. Assessing for hearing loss or aphasia can be part of the process but does not confirm that communication was understood.
Correct Answer is C
Explanation
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.