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 D
Explanation
A. Avoid the use of eye contact to allow the patient to express herself without feeling stared at or demeaned.
Avoiding eye contact can make the patient feel ignored or unheard and is generally not effective in active listening.
B. Ask probing questions to direct the conversation and obtain the information needed as efficiently as possible.
Active listening involves allowing the patient to lead the conversation rather than directing it with probing questions.
C. Anticipate what the speaker is trying to say and help the patient express herself when she has difficulty with finishing a sentence.
While well-intentioned, finishing sentences can prevent the patient from expressing thoughts fully.
D. Use nonverbal cues such as leaning forward, focusing on the speaker's face, and slightly nodding to indicate that the message has been heard.
Correct Answer is B
Explanation
A. is packing belongings in preparation for discharge. Although discharge is an appropriate time for patient education, it may be too late to introduce complex information that requires practice or understanding. Teaching moments often occur earlier in the care process.
B. says, "How will I remember all the things about my new diet?" This is an ideal teaching moment as the patient is expressing concern and showing readiness to learn about the diet. The nurse can use this moment to provide guidance on strategies to remember dietary instructions.
C. has just returned from surgery for a deviated septum. Immediately post-surgery, the patient may be under the influence of anesthesia or pain medication, limiting their ability to absorb information. Teaching at this time may not be effective.
D. has just been told of the malignancy of his tumor. Right after receiving bad news, patients may experience shock, grief, or distress, making it difficult for them to process additional information. This may not be the right time for education.